Form RI 79 9 is an important form for Rhode Island taxpayers. This form is used to calculate your Rhode Island income tax liability. It's important to understand how to correctly complete this form so that you can pay the correct amount of tax. In this article, we will walk you through how to fill out Form RI 79 9 and explain the various sections of the form. We will also provide some tips on how to get the most out of this form.
These are some details you may want to read before you start using the form ri 79 9.
Question | Answer |
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Form Name | Form Ri 79 9 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | opm form health, ri 79 9 form opm, ri 79 9, opm retirement forms |
UNITED STATES
OFFICE OF PERSONNEL MANAGEMENT
RETIREMENT OPERATIONS
WASHINGTON, DC
For CSRS and FERS Annuitants, Survivor Annuitants, and Former Spouse Annuitants
Date
Claim number
CS
Health Benefits Cancellation/Suspension Confirmation
You asked us to cancel or suspend your enrollment in the Federal Employees Health Benefits Program (FEHBP). Please read the front and back of this form and check only the ONE block that applies to you. Please note that the Affordable Care Act (ACA) requires that individuals maintain minimum essential coverage (MEC). For more information, please visit the IRS website at
A. |
I am cancelling my FEHBP enrollment to be covered under a family member's FEHBP enrollment. |
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If you are cancelling your FEHBP enrollment because you will be covered under your spouse's FEHBP enrollment |
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and your spouse is a Federal employee, please include with this form a copy of your spouse's SF 2809, Health |
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Benefits Registration Form, showing the change to a family enrollment. If your spouse is an annuitant, please give us |
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your spouse's name and annuity claim number. |
Spouse's name (Last, first, middle)
Spouse's claim number
B.
If you cancel FEHBP coverage for this reason, we will coordinate the effective date with the effective date of your new coverage under your spouse's enrollment.
Reenrollment eligibility: As long as you are continuously covered as a family member on your spouse's FEHBP enrollment, you will be eligible to resume your own enrollment if your coverage under your spouse's enrollment ends for any reason.
I am cancelling my FEHBP coverage for reasons other than the situation described in part A.
We will cancel your enrollment effective the end of the month in which we receive this signed and dated form. Any health benefits premiums you pay for a period after the cancellation effective date will be refunded in one of your future monthly annuity payments.
Reenrollment eligibility: If you check this block to cancel your FEHB enrollment, you will not be eligible to reenroll in the FEHBP. Additionally, if you cancel your FEHBP enrollment, you and any family members covered by your enrollment will not be entitled to the free
I certify that I have read and understand the information on cancelling FEHBP coverage. I understand that if I checked block B, I will never again be eligible to enroll in the Federal Employees Health Benefits Program.
Signature
Daytime Telephone No. (including area code) |
Date |
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SUSPENSION INFORMATION IS SHOWN ON THE REVERSE
Previous editions are not usable.
RI
C.
I am suspending my Federal Employees Health Benefits Program (FEHBP) enrollment because I am enrolled
in a Medicare Advantage health plan. Please note: Medicare Parts A and B are not the same as a Medicare Advantage health plan. You CANNOT suspend your FEHBP enrollment if you are covered by Medicare Parts A and/or B only. Any
Questions: Call Medicare at
D.
E.
These Medicare Advantage health plans are Health Maintenance Organizations or
I am suspending my FEHBP enrollment to use TRICARE, TRICARE for Life (enrollees over age 65 with Medicare Parts A and B), Peace Corps, or CHAMPVA. Please suspend my FEHBP enrollment effective
_______________________________. (Carefully consider the effective date of your suspension. Once we
process your request, we are not able to change the effective date.)
To suspend your FEHBP coverage for this reason, you must give us evidence of your eligibility for TRICARE, TRICARE for Life, Peace Corps, or CHAMPVA. Please send us a copy of your Uniformed Services Identification (I.D.) card and if over age 65, you must also send us a copy of your Medicare card showing enrollment in both Medicare Parts A and B (required for TRICARE for Life). To document your eligibility for CHAMPVA, please send us a copy of your CHAMPVA Authorization Card
I am suspending my FEHBP enrollment because I am eligible for coverage under Medicaid or a similar
To suspend your FEHBP coverage for this reason, you must give us evidence of your eligibility for Medicaid or a similar
The following information applies to blocks C, D and E.
Reenrollment: You may voluntarily reenroll in the FEHBP during an annual open season. We will send you an open season package each year with instructions on how to reenroll. If you don't want to reenroll, disregard your open season material.
If you involuntarily lose your coverage under one of the programs mentioned above, you can reenroll in the FEHBP effective the day after your coverage ends. You must provide evidence of your involuntary loss of coverage. Your request to reenroll must be received at the Office of Personnel Management (OPM) within the period beginning 31 days before and ending 60 days after your coverage ends. Otherwise, you must wait until open season to reenroll.
I certify that I have read and understand the information on suspending FEHBP coverage. I have checked the block relating to my suspension, and I have enclosed the appropriate documentation.
Signature
Daytime Telephone No. (including area code) |
Date |
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Reverse of RI