Dependent Eligibility Verification Documentation List To keep our records accurate and current, we ask you to complete the dependent eligibility verification form and provide documentation for dependents covered on your benefit plans. If you do not take action by February 23, 2013, your dependents’ coverage may end as of January 1, 2013. There are two parts to the dependent verification:

Signed and dated Dependent Audit Form (found in the activity center of HR/Payroll Connection, http://home.catholichealth.net)

Required documentation (see list below) The audit is an administrative process meant to certify that all participants of our benefits programs are eligible to participate. Thank you for helping us keep our benefits program running fairly and efficiently. If you do not send the required information, your dependent coverage will end retroactive to January 1, 2013. Documentation requirements

Fax or mail a copy of the following eligibility documents for each covered dependent. Do not mail original documents because they will be destroyed. In most instances, the documentation is needed to verify: The dependent’s relationship to the household Dependent’s age Before sending copies of your documentation, black out the following if they appear: Social Security numbers Account numbers Financial information Acceptable documentation

Dependent Documentation

Spouse (2 or 3 documents required)

Marriage license, or

Church/justice of the peace marriage certificate

and

Current or previous tax year’s federal tax return if filing jointly (first page only), or

Both spouses’ federal tax returns if filing separately (first page only), or

Copy of tax confirmation notice(s) if filed online showing name(s) and filing married

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Dependent Documentation

Common-law spouse (2 or 3 documents required)

Documents demonstrating fulfillment of state requirements for common-law marriage,

and

Most recent joint federal tax return if filing jointly (first page only), or

Both spouses’ federal tax returns if filing separately (first page only), or

Copy of tax confirmation notice(s) if filed online showing name(s) and filing married.

Child up to age 26 (1 or 2 documents required)

Birth certificate for biological children showing you as parent, or

Court papers for adopted children or children placed for adoption, or

Court papers demonstrating legal guardianship or custodianship for court-appointed children, or

Documentation on hospital letterhead indicating birth date of child, showing you as parent (acceptable only for children under 6 months old if documents above are not available),

and

(Only if documents above do not include birth date) Documented proof of age, such as:

Child’s driver’s license or other government records, or

Child’s visa or passport.

Stepchild up to age 26 (2 or 3 documents required)

Birth certificate showing the child’s parent to be your spouse, or

Documentation on hospital letterhead indicating birth date of child, listing your spouse as parent (acceptable only for children under 6 months old if birth certificate is not available),

and

(Only if documents above do not include birth date) Documented proof of age, such as:

Child’s driver’s license or other government records, or

Child’s visa or passport.

and

Documentation showing your relationship to the stepchild’s parent, such as:

Marriage license, or

Church/justice of the peace marriage certificate, or

Documentation of joint ownership of residence (acceptable only if documents above are not available), or

Joint tenants on lease of residence (acceptable only if documents above are not available).

Who is an eligible dependent? Spouse A spouse is defined as someone of the opposite sex who is legally married, as defined by the law of the state in which the employee resides and within the meaning of the Federal Defense of Marriage Act, to the employee.

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Children Your eligible dependent children include:

A child under age 26 who is a dependent unmarried child of the employee by birth, marriage, legal adoption or placement for adoption, or

A child under age 26 who is in the custody of the employee under court order, or

A child under age 26 who is not living with an employee but for whom the employee is required by law to provide health care coverage, or

A child under age 26 who resides primarily in the employee’s household and for whom the employee has legal custody or guardianship.

A child under age 26 who is dependent on the employee because of a continuous developmental or physical disability that began before age 26.

Audit results After your documentation is received, you will be notified of the audit’s results within 10 business days. You may also return to HR/Payroll Connection online and view the results within 2–3 business days of faxing your documents. For more information If you have questions about the dependent eligibility audit, call the HR/Payroll Connection Support Center at 1-888-450-9450, Monday through Friday, 8 a.m. to 8 p.m. ET.