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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, an Adobe Sign Form 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.