Form 6256 - Designation Of Spouse And/or Dependent Child For Health Insurance Page 2
Download a blank fillable Form 6256 - Designation Of Spouse And/or Dependent Child For Health Insurance in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 6256 - Designation Of Spouse And/or Dependent Child For Health Insurance with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Dependent Information
Dependent
Social Security
Dependent
Name:
Number:
Date of Birth:
Address:
City:
State:
Zip Code:
Relationship to Member:
Natural Child
Adopted Child
Is this dependent married or has this dependent been married previously?
Yes
No
Is this dependent age 18 or older?
Yes
No
Is this dependent a full time student?
Yes
No
Dependent Information
Dependent
Social Security
Dependent
Name:
Number:
Date of Birth:
Address:
City:
State:
Zip Code:
Relationship to Member:
Natural Child
Adopted Child
Is this dependent married or has this dependent been married previously?
Yes
No
Is this dependent age 18 or older?
Yes
No
Is this dependent a full time student?
Yes
No
Certification
I,
, do hereby certify that the person(s) designated above is the retiree's
spouse* and/or dependent child** as defined by law as, "a child in the womb and a natural or legally adopted child of the member
who has neither attained age eighteen(18) nor married or who is an unmarried full-time student who has not attained age twenty-
two (22). I agree that I will immediately provide written notification to Kentucky Retirement Systems as soon as the person(s)
designated above no longer qualifies as a spouse* and/or dependent child** as defined by KRS 16.505(17). I understand that
Kentucky Retirement Systems shall immediately cease to pay the portion of the health insurance premium made on behalf of the
person designated above when that person no longer qualifies as a dependent child** as defined by KRS 16.505(17). I
understand and agree that I will be responsible for and shall be required to repay any insurance benefits paid on behalf of the
person(s) designated above if the said person is not a dependent child** as defined by KRS 16.505(17) or if I fail to notify
Kentucky Retirement Systems when dependent child marries, ceases to be a full-time student, or otherwise ceases to qualify as a
dependent child as defined by KRS 16.505(17).
*105 KAR 1:410
**KRS 16.505(17)
I hereby certify that the information provided on this Form 6256, Designation of Spouse and/or Dependent Child for Health
Insurance, is true and correct. I further acknowledge that I have full understanding that any person who provides a false
statement, report, or representation is subject to penalty or perjury under KRS 523.010 to KRS 523.110.
Signature:
Date:
ADVERTISEMENT
0 votes
Related Articles
Related forms
State Form 946r2 - Change Of Name And/or Address - Public Employee's Retirement Fund - Indiana
Legal
Form Mc 176-2-a - Qualified Medicare Beneficiary (qmb)/specified Low-income Medicare Beneficiary (slmb)/qualifying Individual (qi) Income Eligibility Work Sheet - Couple Or Applicant With An Ineligible Spouse, With Or Without Child(ren)
Legal
Form Mc 175-7 - Sneede V. Kizer Allocation Work Sheet Board And Care Person To Spouse And/or Children At Home Or Ltc Person (afdc-mn/mi) With No Community Spouse To Children At Home
Legal
Form Mc 176 Qdwi - Qualified Disabled Working Individual (qdwi) Income Eligibility Work Sheet Couple Or Applicant With An Ineligible Spouse, With Or Without Child(ren)
Legal
Form Dhcs 0002 - California Proof Of Citizenship And Identity New Requirements For Medi-cal Beneficiaries Who Are U.s. Citizens Or Nationals (armenian) - Health And Human Services Agency
Legal
Related Categories
Parent category: Legal