IMPORTANT INFORMATION About Your ELIGIBILITY For HEALTH ...

Certification of Spousal and Dependent Eligibility: July 1, 2006– June 30, 2007
In accordance with the Working Spouse Rule, enrollment of a spouse (and other dependents when applicable) may
result in additional cost to the employee/ retiree. To certify that your spouse/ dependents are eligible for coverage
without the additional cost, you must complete and return this form by May 1, 2006. THIS FORM MUST BE
FILLED OUT EVERY YEAR! Failure to return the form or submission of an incomplete form may result in
additional cost to you.
A. Name of Employee/Retiree B. Spouse’s Name
Social Security # Social Security #
School District
Date of Marriage
Date of Birth
Date of Birth
Active □ Retired □ COBRA □
Employed □ Self-Employed □ Retired □
Unemployed □
Home Address
Name and address of present employer or business
(must be completed)
Home phone
Work phone
C. Is your spouse covered by another health plan other than yours? □No □Yes If yes, name
My spouse is covered by □Part A of Medicare and/or □Part B of Medicare
D. My spouse’s annual earnings in 2005 were:
1. _____More than $98,269 2. _____Less than $98,269 but more than $38,926 3. _____Less than $38,926
Earnings includes
• all wages, salaries, tips, etc. of the spouse; and
• any wages, salaries, tips etc. of the school district (or BOCES) employee/ retiree that are paid by any business or corporation in which
the spouse and/ or school district (or BOCES) employee/ retiree is a full or partial owner.
• If the spouse and/ or school district (or BOCES) employee/ retiree is a full or partial owner of any business or corporation, earnings
also includes a pro-rata share of the business’ and/ or corporations’ taxable income, ordinary income or net profit. For example, if the
spouse and school district employee each own 25% of a corporation’s stock, then 50% of the corporation’s taxable income would be
considered.
• Other income, excluding pension income.
E. SINGLE PARENTS □Widowed □Not married □Divorced
Are children covered under any other health plan? □No □Yes
If yes, name ___________________________
REVERSE SIDE OF FORM MUST BE COMPLETED
Form-WSRCERT2006front
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