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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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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Myers, Joyce (Federal) |
| File Modified | 0000-00-00 |
| File Created | 2023-10-29 |