Hbd 40 Form – Fill Out and Use This PDF

HBD 40 Form is an indispensable part of any successful building project. From Hacienda gated communities to high rise corporates, property developers and owners depend on this comprehensive survey form to capture all pertinent information of their properties. Knowing the condition of their assets, especially in the case of multi dwelling dwellings, is essential for defending against liability claims and helps meet ADA requirements. As mentioned in its namesake, HBD stands for Height and Boundary Determination--essential processes used in measuring building heights or also known as "grade and taxes set back" code enforcement. At survey angles and boundaries found scattered throughout any political jurisdiction, knowing these markers are vital for understanding a property's limits that a registered land surveyor can do with special precision way above and beyond the common DIY methods not accepted by professional practitioners. Now adding other disciplines of expertise such as structure or plan failure analysis or geological data interpretation along with topography overlooks assesses enables industry involved individuals from different backgrounds from neutral assertion outlining the activity instead of opinion casting irrelevant field observations. All this required data fits neatly inside the pages completing it as mandatory precursor under standard industry procedure endeavors where ever applied investigation meets objective results.

Hbd 40 Form PDF Details

When it comes to running a successful business, there's no doubt that staying on top of all the paperwork and forms can be tedious. Having an organized system in place to manage them is essential to keep your office running smoothly. And among those documents stands one particular one: the HBD 40 Form – also known as Habitat Degrading Indemnification Form 40. This critical document serves a very specific purpose for businesses both small and large alike, so if you haven't already dive into understanding what this important form entails, now is the time! In this blog post we'll explore why the HBD 40 Form is used by businesses, what purposes it serves, how you must fill it out correctly when applicable and ultimately should consider applying with yours. Let's get started!

Question	Answer
Form Name	Hbd 40 Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	affidavit parent child relationship form hbd 40, calper annual health recertification hbd 40, pers hbd 40, calpers form hbd40

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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)
Social Security Number:

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

Initials

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

Yes

Initials

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

Yes

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

Initials

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

Yes

Initials

emergency forms.

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

Yes

Initials

school, extracurricular, and other activities.

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

Yes

Initials

please state the reason why.)

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

Yes

Initials

9. Other (please explain or attach explanation):

Yes

Initials

	California Public Employees' Retirement System
HBD-40 (Rev. 6/13)	www.calpers.ca.gov
	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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Concentrate while filling in this pdf. Make sure that each and every blank is filled out accurately.

1. Begin filling out your hbd 40 form with a selection of essential blank fields. Collect all of the information you need and make certain there's nothing forgotten!

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.

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.

4. Filling in Personnel OfficerHuman Resources, Approve, Disapprove Date, PO Box, Sacramento CA, TTY, Phone CalPERS or Fax, and HBD Rev is paramount in the next form section - always don't hurry and fill in every single empty field!

cal hr hbd 40 completion process detailed (step 4)

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Hbd 40 Form – Fill Out and Use This PDF

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