Duval County School Board Dependent Verification/change In Status Acknowledgement Form
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2DUVAL COUNTY SCHOOL BOARD
DEPENDENT VERIFICATION/CHANGE IN STATUS
ACKNOWLEDGEMENT FORM
By signing this form, I attest that I met with a Benefit Representative to properly verify my benefit eligible dependent(s) with
the documents described and checked below. The purpose of this verification establishes eligibility only and does not enroll
my dependents for any benefits. I understand that coverage elections must be made by completing an enrollment form or via
the online benefits enrollment system.
DEPENDENT VERIFICATION
Spouse married prior to current calendar year
IRS 1040 Tax Return for year prior to current calendar year; AND
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Marriage Certificate; AND
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Social Security Number
Spouse Name:______________________________________________ DOB: __________________ SSN:_____________________________ Eff:________________
Spouse married on or after January 1 of current calendar year
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Marriage Certificate; AND
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Social Security Number
Spouse Name:______________________________________________ DOB: __________________ SSN:_____________________________ Eff:________________
Birth Child (Age 0 – 26 years)
Birth Certificate (Hospital Certificate of Birth is acceptable for Newborns) that shows proof of relationship; AND
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Social Security Number
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
Step-Child(ren) (Age 0 – 26 years)
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Marriage Certificate; AND
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Birth Certificate (Hospital Certificate of Birth is acceptable for Newborns) that shows proof of relationship; AND
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Social Security Number
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
Child(ren) under Legal Guardianship/Adoption/Custody/Foster Care (Age 0-26 years)
Birth Certificate (Hospital Certificate of Birth is acceptable for Newborns) that shows proof of relationship; AND
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Legal Guardianship/Adoption/Custody/Foster Care documents from Courts naming employee as legal guardian/adoptive parent/custodian/foster parent; AND
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Social Security Number; AND
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Marriage Certificate if spouse (not employee) is the legal guardian/adoptive parent/custodian/foster parent,
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
Grandchild (ren) (Age 0-18 months)
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Birth Certificate of child(ren) stating child was born to an insured dependent child of the District employee; AND
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Birth Certificate of insured dependent birth parent who is also enrolled in the plan; AND
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Social Security Number
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
Incapacitated or Handicapped Dependents (Age 26+)
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Birth Certificate that shows proof of relationship; AND
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Social Security Number; AND
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Statement from the dependent’s physician certifying that the dependent is incapable of self-sustaining employment by reason of retardation or physical handicap, and is
chiefly dependent upon the employee or retiree for support and maintenance; OR
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Social Security papers
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
Birth outside of USA (not adoption) (Age 0-26 years)
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Naturalization papers; AND
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Social Security Number; OR
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Federal Identification Number
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
Dependent Child Name: ______________________________________ DOB: __________________ SSN:_____________________________ Eff:_______________
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