Employee's Full Name (Last, First, Middle)
Child's SSNRelationship to Employee
Employee's SSN
U.S. Department of State
Privacy Act Statement
AUTHORITY: The information is sought pursuant to the Federal Employees Health Benefits (FEHB) Program - Affordable Care Act, Extension of
Dependent Coverage, 42 U.S.C.§ 300gg-14.
PURPOSE: To comply with the Federal Employees Health Benefits (FEHB) Program - Affordable Care Act (ACA), Public Law 111-148, which allows
eligible foster child(ren) to be covered under their parent's Self and Family enrollment until age 26. The information furnished may also be used to
certify that certain requirements are met.
ROUTINE USES: The personal information including your SSN provided on this form is needed to document your enrollment in the Federal Employee
Health Benefits Program (FEHB) under Chapter 8, Title 5, U.S. Code. This information will be shared with the health insurance carrier you select so
that it may identify your enrollment in the plan, verify you and your family's eligibility for payment of a claim for health benefits services and may be
used as an individual identifier in the FEHB Program.
EFFECTS OF NON-DISCLOSURE: Providing personal information, including your SSN and signing the new certification agreement is voluntary, but
failure to provide certain information and meet requirements may result in denial of health insurance benefits and supplies for eligible foster child(ren).
This is to certify that my foster child meets the following requirements for coverage in the Federal Employees Health
Benefits (FEHB) Program:
1. The child is unmarried and under the age of 26 (If age 26 or older, he/she can only be covered if the child is
incapable of self-support due to a disabling condition that began before the age of 26. Employee must provide
documentation to employing office).
2. The child lives with me in a regular parent-child relationship.
3. I contribute regular and substantial support for the child.
4. I Intend to raise the child into adulthood.
NOTE: If the child is a newborn, provide social security number to health benefits carrier as soon as it becomes
available. Do NOT send the Social Security Number (SSN) to the Human Resources Service Center (HRSC).
Child's Full Name (Last, First, Middle)
Date of Birth (mm-dd-yyyy)
Section 1: Foster child's information: in order to make the alert system effective.
Section 2: Employee Verification Statement
I have enclosed proof of my regular and substantial support for child/foster child listed in Section 1. I have also included
a copy of his/her birth certificate. I will notify the HRSC and my health benefits carrier if the child marries, moves out of
my home, or ceases to be financially dependent on me. If this child move out to live with a biological parent, he/she
loses coverage and cannot ever again be covered as a foster child unless the biological parent dies, is imprisoned, or
becomes incapable of care for the child due to disability.
Phone NumberEmail Address
Signature Date (mm-dd-yyyy)
Send DS-5111, Certification for Foster Child Status, to the HR Service Center at or via fax to
click to sign
click to edit