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| This form can be completed online, but it cannot be submitted online. The information you enter is not saved or submitted to any system. Enter the information in the fields below, then print the form using your browser's print function. If you wish, you may print a PDF of this form and complete it manually. (About PDFs) |
Instructions:
This form should be completed in conjunction with IU’s Health Plan Enrollment Form and Affidavit of Domestic Partnership. The purpose of the form is for an employee to certify that a domestic partner and/or children of the partner are the IRS-defined tax dependents of the employee and therefore not subject to federal or state income taxes assessed on the value of health plan benefits for those individuals. Do not include on this form children of the employee who are eligible dependents of the employee aside from the domestic partner relationship. Carefully read "Important Tax Information for Same-Sex Domestic Partner Benefits."
Employee Information |
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Name: |
Last First Middle |
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Social Security #: - - Date of Birth: / / |
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domestic partner Information |
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Name: |
Last First Middle |
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Social Security #: - - Date of Birth: / / |
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Domestic Partner's Dependent Child(ren) Information |
(List only children of the domestic partner who are IRS-defined ‘dependents’ of the employee for federal income tax purposes.) |
Dependent Child Name (Last, First, Middle) |
Social Security Number |
Date of Birth |
Married |
Full-time Student |
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Y
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Y
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Y
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Y
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Y
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Y
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A. Partner Certification as a Tax-Qualified Dependent
I have read the "Important Tax Information for Same-Sex Domestic Partner Benefits" and, based on consultation with a tax advisor, I certify that the previously named person whom I am enrolling for coverage is my legal tax dependent under IRS Section 152. I understand that falsely certifying dependency status could result in disciplinary action (including termination) from Indiana University, as well as potential charges of tax fraud. I further agree to notify Indiana University immediately of any change in this tax status.
Employee: ________________________________________________ Date: _________________________
B. Dependent Child Certification as a Tax-Qualified Dependent
I have read the "Important Tax Information for Same-Sex Domestic Partner Benefits" and, based on consultation with a tax advisor, I hereby certify that the previously named dependent children whom I am enrolling for coverage is/are my legal tax dependent(s) under IRS Section 152. I understand that falsely certifying dependency status could result in disciplinary action (including termination) from Indiana University, as well as potential charges of tax fraud. I further agree to notify Indiana University immediately of any change in this tax status.
Employee: ________________________________________________ Date: _________________________
Mail to your campus HR Office.
