EMPLOYEE BENEFITS DIVISION 
STATE OF NEW YORK 
DEPARTMENT OF CIVIL SERVICE 
STATEMENT OF DEPENDENCE 
THE STATE CAMPUS 


FOR PARTICIPATION IN THE HEALTH INSURANCE PROGRAM ALBANY, NEW YORK 12239 


INSTRUCTIONS:

This form must be completed when an enrollee applies for coverage on behalf of a dependent child who is other than the enrollee's own child, adopted or dependent stepchild. For such a dependent to be eligible, the child must, among other things, 
(1) reside permanently in the enrollee�s home and 
(2) receive more than 50 percent of support from the enrollee, including medical expenses. 
If you have a dependent who meets these criteria, please complete this form and submit proof of support. Please read carefully, respond accurately and initial your response to each of the following questions. If you have questions, contact your agency Health Benefits Administrator.


Part A� ENROLLEE'S STATEMENT 

The State may request such proof of support and/or residency that may be satisfactory to it. 


PERSONAL PRIVACY PROTECTION LAW NOTIFICATION 

This information is being requested pursuant to Section 164 of the New York State Civil Service Law and NYCRR Rule 73.4 for the principal purpose of determining eligibility of individuals to participate in these programs and to maintain up-to-date records for covered employees. This information will be used in accordance with Section 96. (1) of the Personal Privacy Protection Law, particularly subdivisions (b), (e), and (f). Failure to provide this information may result in the is approval of an individual to participate in these programs or a delay in the payment of benefits. This information will be maintained by the Director of Personnel or the Health Benefit Administrator of the agency where you are employed. For further information relating only to the Personal Privacy Protection Law call (518) 457-9375. This information must be true and accurate, pursuant to the following:  Section 1035 of Title 18 of the United States Code: (a) Whoever, in any matter involving a health care benefit program, knowingly and willfully -(1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact; or (2) makes any materially false, fictitious, or fraudulent statement or representations, or makes or uses any materially false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry, in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 5 years, or both. Section 86.4 of title 11 of the New York Compilation of Rules and Regulations: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Section 176.05 of the Penal Law: A fraudulent insurance act is committed by any person who, knowingly and with intent to defraud presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, self insurer, or purported insurer, or purported self insurer, or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of a commercial insurance policy, or certificate or evidence of self insurance for commercial insurance or commercial self insurance, or a claim for payment or other benefit pursuant to an insurance policy or self insurance program for commercial or personal insurance which he knows to: (i) contain materially false information concerning any fact material thereto; or (ii) conceal, for the purpose of misleading, information concerning any fact material thereto.

 
Date ____________________________	Enrollee's Signature ___________________________________



Sworn to before me this Day of 			Notary Public 


Part B�FOR OFFICE USE ONLY 

THIS FORM MUST BE RETAINED BY THE EMPLOYING AGENCY WITH THE ENROLLEE'S ENROLLMENT RECORDS