Flexible Benefits Program Enrollment And Change Form Page 3
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3ELIGIBILITY CATEGORIES
REQUIRED DOCUMENTS
SPOUSE
• Copy of page 1 of your most-recently filed federal tax return (as filed)
listing spouse (financial data may be blacked out), OR
Your current legal husband or wife
• Copy of official marriage certificate AND a copy of a utility bill with your
spouse’s name on it that is mailed to your home on a regular basis (e.g.,
monthly or quarterly) and dated within the past 60 days.
REGISTERED DOMESTIC PARTNER
• Copy of Declaration of Domestic Partnership (as filed with the official
domestic partner registry), AND
Your domestic partner who is registered with you through
Proof relationship is still current (a copy of a utility bill with your
•
the State of California or any other California County or
registered domestic partner’s name on it that is mailed to your home on
Municipality’s domestic partner registry
a regular basis and dated within the past 60 days.)
One of the following:
CHILD* under the age of 26
• Copy of page 1 of your most-recently filed federal tax return (as filed)
Your child under the age of 26
listing child as dependent , OR
Copy of birth/adoption certificate, Qualified Medical Child Support Order,
•
(certain unmarried children, if handicapped prior to age
or court order of legal guardianship
19 and continuously covered by a County-sponsored
AND
medical plan since prior to age 19, and incapable of self-
support may be eligible beyond age 26, if proper
• Current residence and mailing address, if different than employee
documentation of disability is submitted)
* The basic definition of “child” is the same for all plans: Any natural child, stepchild, child placed with you for
permanent adoption, or child for whom permanent legal custody has been granted, of either you or your current
spouse or registered domestic partner, or both.
Most birth certificates and marriage certificates can be ordered online at , if you don’t already have a copy. For copies
of court documents such as adoption or guardianship proceedings, you can contact the Clerk of Court’s office where the proceedings took
place. Any costs you may incur to obtain your documents will be at your expense.
If you are unable to obtain any of the required documents, please contact County Benefits as soon as possible to determine if there are
acceptable alternatives.
Biweekly Flexible Credits
Full-Time (regularly scheduled to work at least 60 hours per pay period)
CJAAVC, CNA, IUOE, MGMT, SEIU, SPOAVC, VCSCOA, VCPPOA, VEA = $297.00/biweek
VCDSA & VCPFA = $272.00/biweek
Part-Time (regularly scheduled to work 40-59 hours per pay period)
CNA, IUOE, MGMT*, SEIU, SPOAVC, VCDSA, VCSCOA, VCPPOA, VEA = $208.00/biweek
CJAAVC = $297.00/biweek
* Per Management Resolution Section 505, all employees hired or promoted to Management prior to April 1, 2001, are eligible for
a full-time flex credit if they are regularly scheduled to work 40-59 hours per pay period.
PY 2016 – revised 7/1/15
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Parent category: Legal