Form Hca 50-704 Declaration Of Tax Status - Washington State Health Care Authority

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Declaration of Tax Status
Employees and retirees: You must complete and submit this form with your enrollment form when enrolling an individual on
your PEBB coverage who does not qualify as your dependent for federal tax purposes (for example, a registered domestic
partner or their eligible children). A registered domestic partner includes a state registered domestic partner, and a domestic
partner who was qualified under PEBB eligibility criteria as a domestic partner before January 1, 2010, and continuously
enrolled under the subscriber in a PEBB health plan or life insurance (WAC 182-12-260(2)). Consult a tax advisor if you have
questions about whether to declare other dependents.
Under federal law, employer contributions for employee or retiree health insurance are not required to be reported as gross
income for federal income tax. However, if an enrolled PEBB dependent does not qualify as your tax dependent for health
coverage purposes under Internal Revenue Code (IRC) Section 152, as modified by IRC Section 105(b), your employer must
report the fair market value of the dependent’s health insurance as gross income. This does not affect a family member’s
eligibility for PEBB coverage, but it can affect your taxable income. (The value of your dependent’s health insurance is
provided on the back of this page for state agency and higher-education employees, and for retirees enrolled in Medicare Part A
and Part B.)
Does this mean I will be taxed on health benefits for my registered domestic partner and/or their eligible children?
First determine if your registered domestic partner and/or their eligible children are your tax dependents for health coverage
purposes under IRC Section 152, as modified by IRC Section 105(b). If so, then premiums paid by your employer for health
coverage will not be included in determining your taxable income, federal withholding, or employment taxes. If the tax status of
your domestic partner and/or their eligible children changes, you must promptly notify your personnel, payroll, or benefits office
(if an employee), or the PEBB Program (if a retiree). If you don’t, it may affect your tax liability.
How do I determine if my PEBB dependents qualify for pretax benefits?
The Internal Revenue Service (IRS) provides information to help determine a dependent’s tax status at You can
use the Worksheet for Determining Support in IRS Publication 501 to assess whether you provide more than half of a dependent’s
support. Other resources include IRS Publication 555 (Community Property), and Answers to Frequently Asked Questions for
Registered Domestic Partners and Individuals in Civil Unions. You could also consult your personal tax advisor.
Section 1: Dependent Tax Status Information
List below all dependents you are enrolling on your PEBB coverage. Use additional forms for more members.
q Yes, this person qualifies as my tax dependent for health coverage purposes under IRC Section 152, as modified by IRC Section 105(b).
q No, this person does not qualify as my tax dependent for health coverage purposes. I should be taxed on the cost of his or her PEBB
health coverage.
Dependent’s last name
First name
Relationship to subscriber
q Yes, this person qualifies as my tax dependent for health coverage purposes under IRC Section 152, as modified by IRC Section 105(b).
q No, this person does not qualify as my tax dependent for health coverage purposes. I should be taxed on the cost of his or her PEBB
health coverage.
Dependent’s last name
First name
Relationship to subscriber
q Yes, this person qualifies as my tax dependent for health coverage purposes under IRC Section 152, as modified by IRC Section 105(b).
q No, this person does not qualify as my tax dependent for health coverage purposes. I should be taxed on the cost of his or her PEBB
health coverage.
Dependent’s last name
First name
Relationship to subscriber
q Yes, this person qualifies as my tax dependent for health coverage purposes under IRC Section 152, as modified by IRC Section 105(b).
q No, this person does not qualify as my tax dependent for health coverage purposes. I should be taxed on the cost of his or her PEBB
health coverage.
Dependent’s last name
First name
Relationship to subscriber
(continued)
HCA 50-704 (10/15)

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