Affidavit For Owner/employee Not On Payroll Form

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AFFIDAVIT FOR OWNER/EMPLOYEE NOT ON PAYROLL
THIS INSTRUMENT HEREBY ACKNOWLEDGES that the undersigned, ___________________, ("affiant"),
[name]
residing at ___________________________________________, is of legal age, and does hereby swear and affirm that
[address, city, and state]
the following is true and accurate, to the best of [his/her] knowledge, under penalty of perjury:
I am an eligible employee of_______________________, according to the definition of an eligible employee put forth in Rhode
Island Small Group Law 27-50(m): "Eligible employee" means an employee who works on a full-time basis with a normal work
week of thirty (30) or more hours, except that at the employer's sole discretion, the term shall also include an employee who works
on a full-time basis with a normal work week of anywhere between at least seventeen and one-half (17.5) and thirty (30) hours, so
long as this eligibility criterion is applied uniformly among all of the employer's employees and without regard to any health status-
related factor. The term includes a self-employed individual, a sole proprietor, a partner of a partnership, and may include an
independent contractor, if the self-employed individual, sole proprietor, partner, or independent contractor is included as an
employee under a health benefit plan of a small employer, but does not include an employee who works on a temporary or
substitute basis or who works less than seventeen and one-half (17.5) hours per week. Any retiree under contract with any
independently incorporated fire district is also included in the definition of eligible employee. Persons covered under a health
benefit plan pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1986 shall not be considered "eligible employees"
for purposes of minimum participation requirements pursuant to section 27-50-7(d)(9).
I also certify that I do not currently appear on a formal payroll document, or a RI Quarterly Tax and Wage Report. Upon the end of
the tax year, I will be able to justify my wages by submitting the following tax documentation:
Schedule C – Profit or Loss From Business
Schedule F – Profit or Loss From Farming
1099 – Miscellaneous Income
1065K1 – Partners Share of Income
1120 – Corporation Income Tax Return
I further understand that misrepresenting myself as an eligible employee of said company for the purposes of obtaining health
insurance will be treated as fraud and will give Blue Cross the right to void my insurance contract.
Signed this _______ day of ____________, _________.
[day]
[month]
[year]
_______________________________________
Print Name of Affiant
_______________________________________
Signature of Affiant
_______________________________________
_______________________________________
Address
SGU
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Last Updated 3/11/2009

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