Duval County School Board Dependent Verification/change In Status Acknowledgement Form Page 2

Change in Status – Documentation must be submitted to Employee Benefits within 60 Days of the event.

Change in Employment Status

___

Letter on company letter head from employer showing employment and insurance effective/termination date

List the dependents added or dropped as a result of this change in status:

__add

__ drop

Spouse:____________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

Change in Marital/ Dependent Eligibility Status

___

Marriage Certificate/Divorce Decree; OR

___

Death certificate of dependent child and/or spouse; OR

Dependent child has reached the maximum age limit of 26 years old; OR

___

Dependent grandchild has reached the maximum age limit of 18 months; OR

___

___

Letter on company letterhead from employer indicating child no longer meets eligibility requirements with the effective/termination date; OR

___

Letter on company letterhead from employer indicating spouse and/or child are being added to or dropped due to change in status

List the dependents added or dropped as a result of this change in status:

__add

__ drop

Spouse:____________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

Change in Number of Employee’s Dependents

___

Birth Certificate or Hospital Certificate with Foot Prints

___

Adoption papers or placement for adoption papers

___

Legal Custody papers

List the dependents added or dropped as a result of this change in status:

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

Change in Dependent Care

___

Letter from the day care which outlines the type of change (i.e. increase/decrease in cost, no longer provides services) and effective/termination date

___

Letter from employee indicating the child has reached the maximum age limit of 13

List the dependents added or dropped as a result of this change in status:

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

Florida Kidcare/ Medicaid/Medicare/Tricare/Healthcare Exchange

___

Florida Kidcare/Medicaid/Medicare/TRICARE approval or disapproval letter and/or ID card with effective date

List the dependents added or dropped as a result of this change in status:

__add

__ drop

Spouse:____________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

Open Enrollment under Other Employer’s Plan

Open Enrollment election form with the company’s name on it ; OR

___

___

Letter on company letterhead indicating the Open Enrollment Period and effective/termination date of coverage

List the dependents added or dropped as a result of this change in status:

__add

__ drop

Spouse:____________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

Judgment/Decree/Order

___

Legal Court documentation that outlines the judge’s orders to provide/terminate benefits

List the dependents added or dropped as a result of this change in status:

__add

__ drop

Spouse:____________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

Health Care Exchange

___

Approval/termination letter from insurance carrier with effective/termination date of coverage

List the dependents added or dropped as a result of this change in status:

__add

__ drop

Spouse:____________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

__add

__ drop

Child: ______________________________________________ DOB: _____________ SSN:________________________ Eff:_____________

I certify that, to the best of my knowledge, the information I have provided is truthful.

______________________________________________________________________________________

______________________________________________________________________________________________________________________________

Printed Name of Employee

Signature of Employee

Date

_______________________________________________

______________________________________________________________________

Employee ID Number

Printed Name of Benefit Representative

Notice of Social Security Disclosure

State laws require agencies that are required to collect employee Social Security numbers (SSN) to disclose the purpose for collecting the SSN. The Duval County School Board is allowed to collect SSN’s when specially authorized by law to do so

or when the collection is imperative for the performance of the District’s duties and responsibilities. Pursuant to Federal and State Laws, the District is collecting your Social Security number for the purpose of processing employee and dependent

benefits; this collection is Mandatory. If you do not provide your SSN, Duval County School Board cannot process your application/request. The Duval County School Board will not disclose your SSN to anyone outside of the District except as

authorized by law.

Revised 8/10/15