Form PS-457 at a glance
What it is: Form PS-457 is the Enrollment or Recertification of an “Other” Child as a NYSHIP Dependent Form of the Department of Civil Service, Albany, NY 12239.
This form must be completed when an enrollee applies or recertifies for coverage on behalf of a dependent child who is other than the enrollee's natural-born or adopted child, stepchild, or the child of the enrollee's Domestic Partner.
For a dependent to be eligible, the child must: (1) have begun residing permanently in the enrollee's home before reaching age 19 and continue to do so, and (2) have begun receiving more than 50 percent of their support from the enrollee before reaching age 19 and continue to receive such support.
What to bring and attach to Form PS-457
If you have a dependent who meets these criteria, please complete this form and submit it along with all required dependent proofs, including a birth certificate, proof of support and a completed NYSHIP Health Insurance Transaction Form (PS-404 for NY and PE enrollees, PS-503 for PA enrollees).
If you are applying for initial enrollment of a child of any age or recertifying an “other” child who is under the age of 19, please attach one proof that documents your support.
If you are recertifying your “other” child who is age 19 or older, please attach one proof that shows the dependent's residence matches your permanent address on file. The proof submitted must have been issued within 6 months of the application date.
A filled-in Form PS-457 example: an enrollee enrolls an “other” child
How to fill out Form PS-457, box by box
Employee information
You must complete boxes 1-6 with your personal information.
“Other” child information
You must complete boxes 7-9 with your “other” child's personal information.
This application is for
In box 10, indicate if this application is for an initial enrollment or a recertification.
Enrollee statement
In the ENROLLEE STATEMENT section, check the boxes to confirm each statement applies to your “other” child. You must also provide the necessary proofs listed on the instructions page. If applicable, enter the date and reason.
I provide at least 50 percent of the dependent's financial support. My home address on file is this dependent's permanent legal residence. I anticipate that the dependent will reside with me for at least 2 years, unless: They will lose eligibility or obtain their own health coverage through employment during the next two years, or They are living away from home for college or in a dorm while my home remains their permanent address.
Reside with you for less than 2 years
If you anticipate that the dependent will reside with you for less than 2 years, please specify when and why.
More rules for Form PS-457
The PS-457 Instructions (3/2026) from the Department of Civil Service, Albany, NY 12239 say: complete this form fully, sign it, and have it notarized.
You must also submit the necessary proofs to apply for or recertify coverage for your “other” child.
Examples of an acceptable proof of financial support include: A signed and completed copy of your federal tax return for the current tax year, claiming the “other” child as a dependent; A letter from a licensed CPA (Certified Public Accountant) or an attorney, confirming that you can claim the dependent on your current federal tax return; Proof of legal guardianship.
Letters from general tax preparers or tax preparation services are not acceptable.
Proof of legal guardianship must be a court order. A notarized letter from a parent is not acceptable.
Examples of an acceptable proof of residence for the dependent include: Bank statement; Paycheck stub; Driver's license or automobile registration; Tax return (current year); Telephone or utility bill; or Student billing statement from an educational institution.
I understand that any false or misleading statements made on this form of the Department of Civil Service, Albany, NY 12239 will subject me to financial responsibility for any benefits paid on behalf of my “other” child.
Common questions about Form PS-457
Does it need a notary?
Sign and date the form in the presence of a notary public. The notary must complete and stamp the form to validate your application.
Sources
[1] Form PS-457 (3/2026), Enrollment or Recertification of an “Other” Child as a NYSHIP Dependent Form, Department of Civil Service, New York State (the Official source link on this page).