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DependentIneligibility Affidavit This form is to be used to affirm that a dependent qualifying child/qualifying relative, is NOT eligible for coverage under PEA. Must be notarized. I, hereby affirm

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What is dependent ineligibility affidavit?

Dependent ineligibility affidavit is a form used to declare that a particular dependent is not eligible for certain benefits or entitlements.

Who is required to file dependent ineligibility affidavit?

Individuals who have dependents that are not eligible for certain benefits or entitlements are required to file dependent ineligibility affidavit.

How to fill out dependent ineligibility affidavit?

Dependent ineligibility affidavit can be filled out by providing the necessary information about the dependent and the reasons for their ineligibility for benefits.

What is the purpose of dependent ineligibility affidavit?

The purpose of dependent ineligibility affidavit is to ensure that only eligible dependents receive benefits or entitlements.

What information must be reported on dependent ineligibility affidavit?

Dependent ineligibility affidavit must include the dependent's personal information and the reasons for their ineligibility for benefits.

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