Dependent Tax Status Change Form UW1541

University of Wisconsin System
Instructions for completing the Dependent Tax Status Change Form for State Group Health Insurance
You must submit this form to your institution/campus Payroll and Benefit Office if you are changing the tax status of a dependent.
SECTION 1 – APPLICANT INFORMATION
1.
Print your responses clearly and legibly.
2.
Enter your complete name (including your previous name, if applicable), your home address, and your home and daytime telephone
numbers in the spaces provided.
3.
Eligibility Status: Check the box which describes your status as an applicant.
4.
A tax status change is made for an entire tax year. Because health insurance premiums are paid two months in advance of coverage,
a tax status change made between November 1 and October 31 is effective for the tax year starting January 1 within this time period.
SECTION 2 – TAX STATUS CHANGE
1.
List only the dependent(s) whose tax status is being changed.
2.
Indicate “Yes” or “No” if your domestic partner and/or dependent child is considered a “tax dependent” under federal tax law. You do
not need to complete this box for your spouse. Note there may be tax consequences to you when you cover dependents (i.e.,
domestic partners and children) that are not dependent on you for at least 50% of their support.
Please consult your tax advisor when determining the tax status of dependents. See IRS Publication 501 (2009), located online at
http://www.irs.gov/pub/irs-pdf/p501.pdf. Note: The gross income limit does not apply for purposes of determining tax dependent
status when you are covering the person on your health insurance policy.
Review the Tax Dependent Worksheet located at http://www.bussvc.wisc.edu/ecbs/Tax_Dependent_Status_Worksheet.pdf
to determine if your adult child or domestic partner is a tax dependent.
For domestic partner health insurance information, please review Domestic Partner Benefits (ET-2370), located at
http://etf.wi.gov/publications/et2370.pdf
For eligible adult child health insurance information, please review Benefit Eligibility for Adult Children up to Age 27, located at
http://etf.wi.gov/publications/dependent_mandate_2010.pdf
SECTION 3 – SIGNATURE
1. Read the TERMS AND CONDITIONS below.
2. Sign and date the form.
TERMS AND CONDITIONS
1.
2.
Under the penalties of perjury, I declare that I have examined this Dependent Tax Status Change Form and to the best of my
knowledge and belief, all statements and answers are true, correct, and complete. (This form is not valid unless you sign it.)
Any children, as defined in the contract, listed on this application are not married and not eligible for coverage under a group
health insurance plan that is offered by their employer for which the amount of their premium contribution is not greater than
the premium amount for their coverage under this program. Children may be covered through the end of the month in which
they turn 27. Children may also be covered beyond age 27 if they:
 have a disability of long standing duration, are dependent on me or the other parent for at least 50% of support and
maintenance, and are incapable of self-support; or
3.
4.
 are full-time students and were called to federal active duty when they were under the age of 27 years and while they were
attending, on a full-time basis, an institution of higher education; and if the adult child has applied for full-time student status
at an institution of higher education, within 12 months after completing active duty; and if the adult child is called more than
once in four years of the first call to active duty, insurers and self-insured health plans may only use the adult child’s age at
the time of the first call to active duty to determine eligibility.
I understand that if my insured domestic partner and/or adult dependent children of my domestic partner are not considered
tax dependents for group health insurance purposes under federal tax law, my income will include the fair market value of the
health insurance benefits provided to my domestic partner and/or adult dependent children of my domestic partner. I understand that this may affect my federal and state taxable income and increase my tax liability.
I understand that if my insured adult child turning age 27 in the current calendar year is not considered a tax dependent for
group health insurance purposes under federal tax law, my income will include the fair market value of the health insurance
benefits provided to my adult children. I understand that this may affect my federal and state taxable income and increase my
tax liability.
I understand that if my insured adult children age 26 or under are not considered tax dependents for group health insurance
purposes under State of Wisconsin tax law, my income will include the fair market value of health insurance benefits provided
to my adult children. I understand that this may affect my state of Wisconsin taxable income and increase my state tax liability.
I understand that it is my responsibility to notify my employer if there is a change affecting my coverage. This form applies to a
change in the “tax dependent” status of my domestic partner and/or dependent children. Upon request, I agree to provide any
documentation that ETF or my employer deems necessary to substantiate my eligibility or that of my dependents.
UW1541 (REV 07/2010)
Ensure Highlight Fields, found in the top
right corner, has been selected. Data
University of Wisconsin System
fields will be highlighted when this feature
is enabled. Click to check a box or enter
DEPENDENT TAX STATUS CHANGE FORM
data in a field; use the Tab key to move
FOR STATE GROUP HEALTH INSURANCE
to the next field.
Employer Notes
Use this form if you are ONLY making dependent tax status changes.
Tax status changes due to qualifying events and all other changes should be
submitted on the Health Insurance Application/Change Form (ET-2301).
You may want to consult your tax advisor when determining the tax status of dependents.
1. UW EMPLOYEE INFORMATION
Employee – Last Name
Address—Street and No.
First
Middle
Cit
y
Home Telephone No.
Previous Name
Social Security Number
State
Zip Code
Daytime Telephone No.
CHANGE TO BE EFFECTIVE
for the Tax Year __________________
ELIGIBILITY STATUS (check one)
Employee
Graduate Assistant
CURRENT HEALTH PLAN ______________________________________________________________
2. TAX STATUS CHANGE
Tax Dependent?
Last Name
First
Middle (Prev
(Y/N)
ious Name)
Spouse/Domestic Partner
Dependent
Dependent
Dependent
Dependent
3. SIGNATURE
I wish to change the tax status of a dependent. I have read, understand, and agree to the Terms and Conditions accompanying this form.
Reason for change _________________________________________________________________________________________
Under the penalties of perjury, I declare that I have examined this Dependent Tax Status Change Form and to the best of my
knowledge and belief, all statements and answers are true, correct, and complete. (This form is not valid unless you sign it.)
SIGN HERE
& Return to
Employer
Date Signed (MM/DD/YYYY)
Applicant Signature

4. EMPLOYER COMPLETES
Date Application Received by Employer
(MM/DD/YYYY)
DDEN TAX FIELD UPDATED
COPY AND DISTRIBUTE:
UW1541 (REV 0/2010)
Payroll Representative Signature
Telephone
(
ETF TAX STATUS UPDATED
EMPLOYEE FILE
ADJUSTMENT/REFUND REQUESTED
UWSC
)
PROCESSED BY/DATE/PHONE
Employee should retain a copy for her/his records.