It must be completed when an enrollee applies or recertifies for coverage on behalf of a dependent child other than the enrollee's natural-born or adopted child, stepchild or Domestic Partner's child.
Residing: the child must have begun residing permanently in the enrollee's home before reaching age 19 and continue to do so.
Support: the child must also have begun receiving more than 50 percent of their support from the enrollee before reaching age 19 and continue to receive such support.
Proofs: submit it with all required dependent proofs, including a birth certificate, proof of support and a completed NYSHIP Health Insurance Transaction Form.
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.
| Question | Answer |
|---|---|
| Form Name | PS-457 |
| Form Length | 3 pages |
| Fillable? | Yes |
| Fillable fields | 25 |
| Avg. time to fill out | 5 min |
| Edition | 3/2026 |
| Who signs | The enrollee, in the presence of a notary public |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | PS-457, PS 457, PS457, Form PS-457, NYSHIP PS-457, Enrollment or Recertification of an Other Child as a NYSHIP Dependent |
| Official source | PS-457 (Rev 3/2026), Department of Civil Service |
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