Forms & publications

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Declaration of tax status 2018

50-704-2018

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.

Form

Declaration of tax status 2019

50-704-2019

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.

Form