Eligibility Questionnaire For Havana Act Payments

Eligibility Questionnaire for HAVANA Act Payments

RELATIONSHIP DOCS - HAVANA Act Payments Collection

ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS

OMB: 0690-0037

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Appendix: Verification of Relationship Documents

The following table lists documents that may establish a relationship between the claimant and the requester. The requester may remove personal financial information and Social Security Numbers before submission. Documents that are not in English must be accompanied by a certified or notarized translation.



Family Member

Acceptable Document(s) to Verify Relationship of Dependent

Adult


Adult Children

Incapable of

self-support

  • Power of Attorney (medical and financial)

  • Guardianship (medical and financial)

  • Conservator

  • Executor of Estate (deceased)



Unmarried Child

under age 21

A copy of any one of the following documents listing child:

  • Government-issued birth certificate; or

  • Certificate of live birth; or

  • Front page of the most recent tax year’s Federal or State tax return; or

  • Consular Report of Birth Abroad; or

  • Official paternity test; or

  • Voluntary affidavit of paternity or similar document; or

  • Court or administrative order (e.g., National Medical Support Notice).

Unmarried Adopted child under age 21

A copy of any one of the following documents listing child:

  • Final adoption certificate or decree; or

  • Authorized letter from a placement agency for the purpose of adoption; or

  • Front page of most recent tax year’s Federal or State tax return with child’s name; or

  • Court or administrative order (e.g., National Medical Support Notice).


Family Member Acceptable Document(s) to Verify Relationship of Dependent

Unmarried stepchild under age 21

A copy of any one of the following documents:

  • Birth certificate, or final adoption certificate/decree, listing current spouse as parent; or

  • Front page of most recent tax year’s Federal or State tax return with child’s name; or

  • Court or administrative order (e.g., National Medical Support Notice)


Unmarried foster child under age 21

Submit all of the following documents:

  • Certification of foster child status, available in Appendix

  • Government-issued birth certificate or other document verifying child’s date of birth.

  • Documentation of regular and substantial support for the child, such as:

    • Evidence of eligibility as a dependent child for benefits under other State or Federal programs.

    • Proof of inclusion of the child as a dependent on the enrollee’s front page of most recent tax year’s Federal or State tax returns.

    • Canceled checks, money orders, or receipts for periodic payments from the enrollee for or on behalf of the child.

    • Evidence of goods or services which show regular and substantial contributions of considerable value.

  • If applicable, include copy of court order naming employee or spouse as child’s legal guardian.


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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorMyers, Joyce (Federal)
File Modified0000-00-00
File Created2023-09-20

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