Get Dependent Child Certification Affidavit - Rutherfordcountytn

Filling out the dependent child certification affidavit is essential for verifying the eligibility of your dependent child for medical insurance. This guide provides clear, step-by-step instructions to assist you in completing the form accurately and submitting it online.

Follow the steps to complete the affidavit successfully.

1. Use the ‘Get Form’ button to access and open the dependent child certification affidavit in your preferred document editor.
2. Begin by carefully reading the instructions at the top of the affidavit to ensure you understand the requirements.
3. Fill in your dependent child's name in the designated section, ensuring the spelling is accurate.
4. Provide your dependent child's social security number in the appropriate field.
5. If applicable, complete the section for your dependent child's employer details, including the employer's name, address, city, state, and ZIP code.
6. In the section for the insured member, print your name clearly and fill out your social security number.
7. By signing the affidavit, you confirm the information is accurate and acknowledge your responsibilities regarding dependent eligibility.
8. Date the form to provide the necessary timestamp.
9. Make sure to attach a copy of your dependent child's birth certificate to the completed affidavit.
10. Save your completed affidavit and birth certificate copy, then prepare to submit them by the specified deadline.
11. Submit the completed affidavit and birth certificate to the Rutherford County Insurance Department by mail, ensuring it arrives by the deadline.
12. Do not fax the affidavit; only mailed submissions are acceptable.

Complete your affidavit online today to ensure your dependent child is covered!