Forms & publications

Declaration of Tax Status (PEBB) 2022

Subscribers must submit this form with their enrollment form when enrolling an individual on their coverage who does not qualify as their dependent for federal tax purposes.

Declaration of Tax Status (PEBB) 2023

Employees and retirees must complete and submit this form with their enrollment form when enrolling an individual on their PEBB Program coverage who does not qualify as their dependent for federal tax purposes.