Declaration of Tax Status (PEBB) 2022

50-0704

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.

Form

Declaration of Tax Status (SEBB) 2022

20-0087

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.

Form