Cal Poly Jobs is changing! Learn more about how this solution will support our campus recruiting and onboarding efforts.

Learn more   

Affidavit of Parent-Child Relationship

The Affidavit of Parent-Child Relationship allows an employee to enroll a child who is in a Parent-Child relationship to health benefit programs. A parent-child relationship is established when you intentionally assume parental status or duties over a child who is not your adopted, step, or recognized natural child, and meet specific enrollment criteria.

Launch the Affidavit of Parent-Child Relationship Form

Applicant Instructions

  1. After launching the Affidavit of Parent-Child Relationship, a DocuSign PowerForm will prompt you for your name and email.
  2. Complete all required form fields
  3. The following information is needed to complete the Affidavit of Parent-Child Relationship
    • Employee Information: Name, SSN, date of birth, date you assumed primary parental status or duties for the dependent, relationship to dependent.
    • PCR Dependent Information: Name, SSN, date of birth, and address (if different from yours).
  4. Please note that you must provide the following supporting documentation to provide evidence of your assumed parental status or duties.
    • For a PCR dependent under Age 19: A copy of the first page of your income tax return from the previous tax year listing the child as a dependent. In lieu of a tax return, for a time not to exceed one filing year, you may submit other documents that substantiate the child's financial dependence upon you, including, but not limited to: current legal judgments/court documents showing the subscriber's legal parental status or duties/guardianship over the child; bank, credit card, tuition or insurance statements/payments; school records; bills or mail indicating common residency with the dependent
    • For a PCR dependent from Age 19 up to Age 26: A copy of the first page of your income tax return from the previous tax year listing the child as a dependent, OR, out suitable PCR documentation (see above) that substantiates that the child is financially dependent upon you provided that the child: either lives with you for more than 50% of the time, or is a full-time student, AND is dependent upon you for more than 50% of the child’s support.