Dependent Name - Human Resources - Syracuse University printable pdf download

Dependent Name - Human Resources - Syracuse University

Syracuse University

Application for Schedule B Medical Contributions

Human Resources, Skytop Office Bldg., 443-4042

EMPLOYEE

Name: ____________________________

SUID#: ___________________

INFORMATION

Number of individuals declared on YOUR Federal Income Tax Return:

________

(Line 6d on Forms 1040 and 1040A; 1 or 2 depending on marital status on Form 1040EZ)

Please submit the first 2 pages of the Income Tax Return with this application.

If filing separately, number of individuals declared on YOUR SPOUSE’S OR

ELIGIBLE DOMESTIC PARTNER’S Federal Income Tax Return:

________

(Line 6d on Forms 1040 and 1040A; 1 or 2 depending on marital status on Form 1040EZ)

Please submit the first 2 pages of the Income Tax Return with this application.

Number of children under the age of 19 who are living with you but are not included

on either of the Federal Income Tax Returns above (for example, children declared

on an ex-spouse’s Federal Income Tax Return):

________

You do not need to submit the Federal Income Tax Return but please list the names

HOUSEHOLD

and birthdates of the children below:

SIZE

Name _______________________________________ Date of Birth____________

Number of children over the age of 19 who are enrolled on your medical plan but are

not included on either of the Federal Income Tax Returns above:

________

List the names and birthdates of the children below:

Name _______________________________________ Date of Birth____________

HR Use Only - Total Household Size

________

HR163

Call the HR Service Center

Originated 10/20/2010

at 443-4042 for assistance

Dependent Name - Human Resources - Syracuse University