/depts/,/depts/uwhealth/,/depts/uwhealth/benefits/,/depts/uwhealth/benefits/open-enrollment/,/depts/uwhealth/benefits/open-enrollment/uwhc-open-enrollment/,/depts/uwhealth/benefits/open-enrollment/uwhc-open-enrollment/domestic-partner/,/depts/uwhealth/benefits/open-enrollment/uwhc-open-enrollment/domestic-partner/resources/,

/depts/uwhealth/benefits/open-enrollment/uwhc-open-enrollment/domestic-partner/resources/UWHC-Declaration-of-Tax-Status.pdf

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Departments & Programs,UW Health,Benefits,UW Health Open Enrollment,UWHC Open Enrollment,Domestic Partner,Resources

Declaration of Tax Status

Declaration of Tax Status - Departments & Programs, UW Health, Benefits, UW Health Open Enrollment, UWHC Open Enrollment, Domestic Partner, Resources


UWHC DECLARATION OF TAX STATUS
Please complete the Declaration of Tax Status form in full to certify eligibility and/or change the tax status of your
domestic partner or children of your domestic partner. This form may be returned to UW Health Human Resources
Benefits, 301 S Westfield Rd, Suite 200, Madison, WI 53717, MC 2409, fax 608-263-5778.
Employee Information (Please PRINT)
Last Name First Name, MI Employee ID # Date of Birth
Home Address City State Zip Code
Domestic Partner Information (Please PRINT)
Last Name First Name, MI Social Security # Date of Birth
 Yes, this person qualifies as my dependent for federal income tax purposes.
 No, this person does not qualify as my dependent for federal income tax purposes.
Children of Domestic Partner (Please PRINT)
Last Name First Name, MI Social Security # Date of Birth
 Yes, this child qualifies as my tax dependent.
 No, this child does not qualify as my tax dependent.
Last Name First Name, MI Social Security # Date of Birth
 Yes, this child qualifies as my tax dependent.
 No, this child does not qualify as my tax dependent.
Last Name First Name, MI Social Security # Date of Birth
 Yes, this child qualifies as my tax dependent.
 No, this child does not qualify as my tax dependent.
Certification
I am providing this information to my employer for insurance and tax reporting purposes. I understand that if the tax
dependency status changes for any of the individuals listed above, I will notify my employer immediately. I understand that
mid-year changes apply to the entire calendar year. I certify that all of the above statements are true and correct. I
understand that falsely certifying to the tax-dependent status of the individuals above may result in adverse tax
consequences and potential charges of tax fraud. Additionally, knowingly making a false statement may subject a person to
termination of enrollment, denial of future enrollment, or civil damages.
_____________________________________________________ ____________________________________________
Employee Signature Date
Employer Section (UWHC Benefits Only)
PS Entry Completed by: Date of Entry:
Health
 Not enrolled
 Pre-tax
 1 Non-tax Dependent
 2+ Non-tax Dependents
Supplemental Delta Dental
 Not enrolled
 Pre-tax
 Post-tax
Notes/Adjustments:
VSP Vision
 Not enrolled
 Pre-tax
 Post-tax
EPIC Benefits +
 Not enrolled
 Pre-tax
 Post-tax
Tax Year 2017
 Annual Election
 Mid-Year Change