Fairfax County Public Schools Dependent Affidavit Form printable pdf download

Fairfax County Public Schools Dependent AFFIDAVIT

I _____________________, a Participant in the Fairfax County Public Schools Medical and or Dental Plan

(“Participant”) attest that the following person is my dependent.

Full Name of Dependent/Spouse ____________________________________ DOB_________

If Spouse complete: The above listed dependent and I were married on ______________ (Date) at

_______________________________________________________(Address and Location).

The primary reason that I cannot provide all of the required documentation for my dependent/spouse to comply with

the FCPS health plan dependent eligibility verification audit is:

I was married in a foreign country and unable to obtain a marriage certificate

because________________________________________________________________

I am newly married as evidenced by my marriage certificate and have not yet filed taxes

I did not file taxes with my spouse, therefore no tax forms indicating a spousal relationship are available

My vital records were destroyed due to fire, flood etc. and cannot be replaced due to

______________________________________________________________________

Other – Explain

_____________________________________________________________________________________

____________________________________________________________

I understand that the completion of this Affidavit is not a guarantee of coverage for my

dependents and further review of this Affidavit will be made to determine my dependents

eligibility.

Dated this ____ day of ________________________ 20___.

Last 4 Digits of Participant’s SS # ______________________

Participant’s Signature______________________________________

STATE OF __________________________

COUNTY OF _________________________

On this ______ day of _______________ 20___, before me, the notary public, personally appeared

________________________ (Participant) known to me to be the person whose name is subscribed to and within this

instrument and acknowledged that they executed the same for the purposes therein contained.

In witness whereof, I hereunto set my hand and official seal.

______________________________ Notary Public

My Commission Expires: __________________

(SEAL)

Fairfax County Public Schools Dependent Affidavit Form