Declaration of tax status (PEBB) 2020

50-704

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 (SEBB) 2020

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

Form