Hbd 40 Form PDF Details

Navigating the complexities of health plan enrollment within public employment systems in California involves understanding specific forms like the HBD-40, which serves a crucial role when an employee or annuitant desires to enroll a child in their CalPERS-sponsored health plan under a unique set of circumstances. This form, known officially as the Affidavit of Parent-Child Relationship, caters to scenarios where the conventional connections of biology, adoption, or marriage do not apply, and instead, an employee or annuitant has taken on a parent-like role for a child. The intricate details span from confirming the assumption of a comprehensive custodial role to providing basic needs and educational support, underscoring the depth of commitment required to establish this special bond. The form includes places for detailed personal information for both the applicant and the child in question, coupled with a checklist that meticulously outlines the responsibilities and obligations assumed by the applicant, acting as the child's primary care parent. Given the legal gravity, the form culminates with a declaration under penalty of perjury, affirming the truthfulness of the provided information and signaling a pledge to update the Health Benefits Officer on any relationship changes. With annual certification required up to the child's 26th birthday, this form is a testament to the legal system's adaptability in recognizing diverse family structures within the public sector's benefits plans.

QuestionAnswer
Form NameHbd 40 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesaffidavit parent child relationship form hbd 40, calper annual health recertification hbd 40, pers hbd 40, calpers form hbd40

Form Preview Example

CAffidavit of Parent-Child RelationshipCalifornia Code of Regulations section 599.500(o)

The Public Employees' Medical and Hospital Care Act (PEMHCA), allows employees and annuitants to enroll family members in a CalPERS-sponsored health plan. Pursuant to Title 2, California Code of Regulations (CCR), section 599.500(o), an employee or annuitant may enroll a child, other than an adopted, step or recognized natural child, in the health plan if the employee or annuitant has assumed a “parent-child relationship” with that child in lieu of the child's adoptive, step or natural parent, up to age 26.

Aparent-child relationship occurs when the employee or annuitant assumes a parental role and is considered the primary care “parent.” Evidence of this relationship may include assuming responsibilities such as providing shelter, clothing, food, child care or education for the child, as well as assuming parental duties, such as providing permission for school activities, health care services, extracurricular, and recreational activities.

Aparent-child relationship must be certified at the time of enrollment for each child and annually thereafter up to age 26. Spouses of your recognized natural, adopted, or stepchild are not eligible for enrollment.

Employee/Annuitant Information

Name:

(First)

(M.I.)

(Last)

Social Security Number:

 

 

What is the date you assumed the primary custodial parental role for the child?

What is your relationship to the child?

Child Information

 

Name:

 

 

Date of Birth:

 

 

 

 

 

 

 

 

Social Security Number:

(First)

(M.I.)

(Last)

 

 

 

 

 

 

 

 

 

 

 

Address (if different from employee/annuitant):

 

 

 

 

 

 

Have you enrolled other children as family members under CCR section 599.500(o)? Yes

No

If yes, what is the number of children enrolled under CCR section 599.500(o)?

NOTE: A new Affidavit of Parent Child-Relationship form must be submitted for each child.

Eligibility

I hereby certify I have assumed a parent-child relationship with the child named above, as evidenced

 

 

Internal Use

 

 

Only (HBO

by the following:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Initials)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. I have assumed a primary custodial role for this child.

 

Yes

No

Initials

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. I am considered the primary care "parent."

 

Yes

No

Initials

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. I have assumed responsibility for providing the essential needs for this

 

Yes

No

Initials

 

 

 

 

 

 

 

 

 

child, such as food, shelter, clothing, and education.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Has the child been placed in your care as a result of foster care?

 

Yes

No

Initials

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. I am listed as the primary contact on school, health, and other

 

Yes

No

Initials

 

 

 

 

 

 

 

 

 

emergency forms.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. I provide parental permission for the child regarding health care services,

 

Yes

No

Initials

 

 

 

 

 

 

 

 

 

school, extracurricular, and other activities.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. The child is living with me. (If the child is not currently living with you,

 

Yes

No

Initials

 

 

 

 

 

 

 

 

 

please state the reason why.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. I claim the child as my dependent for income tax purposes.

 

Yes

No

Initials

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. Other (please explain or attach explanation):

 

 

 

Yes

No

Initials

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

California Public Employees' Retirement System

HBD-40 (Rev. 6/13)

www.calpers.ca.gov

 

I recognize this affidavit is a legally binding document. I accept full responsibility for notifying my Health Benefits Officer in writing if there are any changes pertaining to this parent-child relationship. Active employees contact your Health Benefits Officer. Retirees contact CalPERS. I further understand the provision of California Government Code 20085, which states:

(a)It is unlawful for a person to do any of the following:

(1)Make, or cause to be made, any knowingly false material statement or material representation, to knowingly fail to disclose a material fact, or to otherwise provide false information with the intent to use it, or allow it to be used, to obtain, receive, continue, increase, deny or reduce any benefit administered by this system.

(2)Present, or cause to be presented, any knowingly false material statement or material representation for the purpose of supporting or opposing an application for any benefit administered by this system.

I hereby certify under penalty of perjury, that the information provided by me is true and correct to the best of my knowledge. I also agree to provide supporting documentation such as, but not limited to, court records, birth certificate, tax returns, statement of financial liability, or any other documents, when requested by my employer or CalPERS. I understand that each child, other than recognized natural, adopted, or stepchild, for whom I assume a parent-child relationship, must be certified at the time of enrollment and annually thereafter up to age 26.

Employee/Annuitant Signature

Date

For Employer Use:

I hereby certify under penalty of perjury as follows:

That I am a duly appointed, qualified, and acting officer of the below named agency.

I hereby certify I have reviewed the above application and verified the identity of the employee submitting this affidavit.

Based on the information provided and any attached documentation, I am approving the enrollment of this child according to CCR section 599.500(o).

Recommend not approving the enrollment of this child.

Health Benefits Officer Signature

Agency Name

Date

 

 

 

 

 

 

 

Personnel Officer/Human Resources Manager

Approve

Disapprove Date

 

 

 

 

 

 

 

P.O. Box 942715

Sacramento, CA 94229-2715

TTY (877) 249-7442

Phone: (888) CalPERS (or 888-225-7377); Fax (800) 959-6545

HBD-40 (Rev. 6/13)

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Step no. 1 in filling out cal hr hbd 40

2. The subsequent part is usually to submit all of the following blank fields: I have assumed responsibility for, child such as food shelter, Has the child been placed in your, I am listed as the primary, emergency forms, I provide parental permission for, school extracurricular and other, Yes, Initials, Yes, Initials, Yes, Initials, Yes, and Initials.

Filling in part 2 in cal hr hbd 40

3. This part is simple - fill out every one of the form fields in I hereby certify under penalty of, EmployeeAnnuitant Signature, Date, For Employer Use, I hereby certify under penalty of, That I am a duly appointed, I hereby certify I have reviewed, Based on the information provided, and Recommend not approving the to finish this process.

cal hr hbd 40 conclusion process outlined (part 3)

When it comes to EmployeeAnnuitant Signature and Based on the information provided, make sure you review things in this section. Both these are considered the key fields in the PDF.

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cal hr hbd 40 completion process detailed (step 4)

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