Declaration That Enrolled Dependent Meets Irs Requirements

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Form 3027
Declaration that Enrolled Dependent Meets
IRS Requirements for Tax-Favored
Health Premium Contributions
This form should be used for a qualifying domestic partner, and children of a domestic partner.
Health Insurance Subscriber:
Last Name
First Name
Social Security Number
Enrolled Dependent:
Last Name
First Name
Social Security Number
You must complete one form for each enrolled dependent.
Declaration:
I, LANS Health Plan Subscriber, have the dependent listed above enrolled on my LANS Health Insurance coverage
and certify that he or she meets all the IRS criteria required, so the employer health premium contributions and/or
deductions for this dependent will not result in imputed income, and may qualify for other favorable tax treatment in
accordance with federal and state law.
By signing this declaration, I certify that I understand that all of the following requirements for this
dependent will be met for the current tax year under Internal Revenue Code (IRC) Sections 105 and 152:
1. I will live together (share our principal abode) with this enrolled dependent for the full taxable year from January 1 to
December 31, except for temporary absences for reasons such as vacation, military service, or education;
2. This enrolled dependent is a U.S. citizen, U.S. national, or a resident of the U.S., Canada or Mexico;
3. This enrolled dependent will receive more than half of his or her support from me during the current tax year.
4. This enrolled dependent is not my “qualifying child” nor anyone else’s “qualifying child.”
• I agree that I will notify LANS HR-Benefits Service Center within 31 days if there is any change in the
circumstances attested to in this declaration, including any change that disqualifies this dependent as being
eligible for LANS Health Plan benefits.
• I have read and understand the terms and conditions listed on the back of this declaration.
• I understand that falsely certifying such qualification could result in serious consequences, including termination from
employment and/or legal action.
• I am aware that any change in family status may directly impact the calculation of my taxable income.
• I will submit this completed declaration to LANS HR-Benefits Service Center by required deadlines to have my
payroll deductions for health benefits changed during the next applicable pay period.
I declare under penalty of perjury the foregoing is true and correct.
Signature:__________________________________
Date:____________________________
(LANS employees are not authorized to give tax advice. Please consult with your personal tax advisor if you have any questions.
How to Return Your Completed and Signed Declaration Form
Make a copy of your completed and signed form for your records and mail the original to:
LANS Benefits Service Center
P.O. Box 1663, MS P280
Los Alamos, NM 87545-0001
Form 3027 (5/14)
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