Eligibility Questionnaire For Havana Act Payments

Appendix: Verification of Relationship Documents

The following table lists documents that may establish a relationship between the claimant and the requester. The requester may remove personal financial information and Social Security Numbers before submission. Documents that are not in English must be accompanied by a certified or notarized translation.

Family Member	Acceptable Document(s) to Verify Relationship of Dependent
Adult Adult Children Incapable of self-support	Power of Attorney (medical and financial) Guardianship (medical and financial) Conservator Executor of Estate (deceased)
Unmarried Child under age 21	A copy of any one of the following documents listing child: Government-issued birth certificate; or Certificate of live birth; or Front page of the most recent tax year’s Federal or State tax return; or Consular Report of Birth Abroad; or Official paternity test; or Voluntary affidavit of paternity or similar document; or Court or administrative order (e.g., National Medical Support Notice).
Unmarried Adopted child under age 21	A copy of any one of the following documents listing child: Final adoption certificate or decree; or Authorized letter from a placement agency for the purpose of adoption; or Front page of most recent tax year’s Federal or State tax return with child’s name; or Court or administrative order (e.g., National Medical Support Notice).

Family Member Acceptable Document(s) to Verify Relationship of Dependent
Unmarried stepchild under age 21	A copy of any one of the following documents: Birth certificate, or final adoption certificate/decree, listing current spouse as parent; or Front page of most recent tax year’s Federal or State tax return with child’s name; or Court or administrative order (e.g., National Medical Support Notice)
Unmarried foster child under age 21	Submit all of the following documents: Certification of foster child status, available in Appendix Government-issued birth certificate or other document verifying child’s date of birth. Documentation of regular and substantial support for the child, such as: Evidence of eligibility as a dependent child for benefits under other State or Federal programs. Proof of inclusion of the child as a dependent on the enrollee’s front page of most recent tax year’s Federal or State tax returns. Canceled checks, money orders, or receipts for periodic payments from the enrollee for or on behalf of the child. Evidence of goods or services which show regular and substantial contributions of considerable value. If applicable, include copy of court order naming employee or spouse as child’s legal guardian.

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