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

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

Declaration of Tax Status

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


Declaration of Tax Status Form
Employees: Return completed form via fax: 608-263-5778 or Ask HR form
UW Health Human Resources to Complete:
PS Entry Completed By: ___________________ Date of Entry: ______________
This form is only completed if you are enrolling your Domestic Partner (DP), Qualifying Child (with a disability) or
Qualifying Relative in medical and/or dental coverage. The Affordable Care Act requires group health plans to
provide dependent medical coverage of children up to the age of 26. UWMF also offers a dental plan which
covers unmarried dependents up to the age of 25. This form does not get completed in these cases.

The University of Wisconsin Medical Foundation (UWMF) offers health and dental coverage to qualified domestic partners, qualified adult child(ren) or relative(s). Qualified child(ren) or relatives are typically an
adult the employee has guardianship over due to permanent and total disability, including children over the age of 25. Please see Human Resources if this situation may apply to you.
To ensure proper taxation of the cost of health and dental insurance applicable to the Domestic Partner or qualified adult, UWMF must know the Federal and/or State tax status of these individuals. The tax status
of these family members doesn’t affect their eligibility for coverage, but does affect whether you (the subscriber) will be taxed on the value of their health coverage.
Section 1: Determining Dependent’s Federal and/or State Tax Status
Complete and return this form to declare whether your Domestic Partner or Other Qualifying Relative qualifies as an Internal Revenue Code (IRC) Section 152 dependent. Please apply the following tests to each dependent to determine their
Federal and/or State Tax Status. Note that the individual(s) has to pass Test A OR Test B in order to qualify as an IRC Section 152 dependent. We recommend that you consult your tax advisor if you have questions about your specific
circumstances. Note: If applicable, domestic partner coverage is subject to State and Federal Taxes.
TEST A: Qualifying Child TEST B: Qualifying Relative
IRC requires a qualifying child meet all of the following tests to qualify as your tax dependent:
1. The child must be your son, daughter, stepchild, foster child, brother, sister, half-sibling, step-sibling, or a descendant of any of
them.
2. The child must be (a) under age 19 at the end of the year and younger than you (or your spouse, if filing jointly), (b) under age 24
at the end of the year, a FT student and younger than you (or your spouse, if filing jointly), or (c) any age if permanently and totally
disabled.
3. The child must have lived with you for more than half the year (exceptions exist).
4. The child must not have provided more than half of his or her own support for the year.
5. The child is not filing a joint return for the year (unless that return is filed only as a claim for refund).
6. If the child meets the rules to be a qualifying child of more than one person, only one person can actually treat the child as a
qualifying child.
7. Special rule for disabled: In the case of an individual who is permanently and totally disabled, as defined in section 22 (e)(3)
which states an individual is permanently and totally disabled if he is unable to engage in any substantial gainful activity by reason
of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be
expected to last for a continuous period of not less than 12 months. An individual shall not be considered to be permanently and
totally disabled unless he furnishes proof of the existence thereof in such form and manner, and at such times, as may be required.
OR
The IRC requires that a qualifying relative meet all of the following tests to qualify as your tax
dependent:
1. The person cannot be your qualifying child or the qualifying child of any other taxpayer.
2. The person either (a) must be related to you in one of the ways listed under ‘Relatives
who do not live with you’, or (b) must live with you all year as a member of your
household (and your relationship must not violate the law).
3. The person’s gross income for the year must be less than $3,700 (there is an exception
if the person is disabled and has income from a sheltered workshop.
4. You must provide more than half of the person’s total support for the year (There are
exceptions for multiple support agreements, children of divorced or separated parents
or parents who live apart, and kidnapped children).
Additional information can be found at www.irs.gov/publications/p17/ch03.html
Section 2: Dependent Tax Status Information
With the exception of your spouse, list the individuals over the age of 18 that you wish to enroll as a Qualifying Child or Qualifying Relative (including Domestic Partner, and indicate whether they qualify as your
Federal and/or State tax dependent.
Qualifying Child or Relative Name Date of Birth SSN Relationship to Employee Federal and/or State Tax Status
I am part of a same sex marriage and was married in a state that recognizes same sex marriage.
Yes, this person qualifies as my IRC Section 152 dependent
No, this person does not qualify as my IRC Section 152
dependent. Federal &/or State taxes will be applied to the cost of their coverage.
I am part of a same sex marriage and was married in a state that recognizes same sex marriage.
Yes, this person qualifies as my IRC Section 152 dependent
No, this person does not qualify as my IRC Section 152
dependent. Federal &/or State taxes will be applied to the cost of their coverage.
Section 3: Signature - Required
I declare that the information I have provided is true, complete and correct. If it is not, or if I do not update this information within the timeliness in UWMF rules, I must repay any premiums that have been paid on my behalf. I understand that
knowingly providing false, incomplete, or misleading information to UWMF for the purpose of defrauding the company will result in appropriate discipline.
I understand that:
ξ This declaration of responsibility may have legal implications under Federal and/or State law.
ξ A civil action may be brought against me for any losses, including reasonable attorney’s fees, if I have made a false statement in this declaration.
ξ I must notify UWMF human resources if there is a change in my domestic partnership or dependent status no later than 60 days after the change. Any change in my family status may directly impact the calculation of my taxable
income.
UWMF’s Privacy Notice: We will keep your information private as allowed by law.
Employee’s printed name ____________________________________________________________ Employee ID_________________
Employee’s Signature _______________________________________________________________ Date________________________
Open Enrollment 2018