CERTIFICATION OF DEPENDENT TAX STATUS FOR PURPOSES OF COVERAGE 

UNDER FEHB AND FEDVIP

The Office of Personnel Management (OPM) permits coverage under the Federal Employees Health 

Benefits (FEHB) Program and the Federal Employees Dental and Vision Insurance Program (FEDVIP) 

for the children of a same-sex domestic partner of a Federal employee or annuitant whom the employee 

or annuitant would marry but for the fact that the law in his or her state of residence does not permit 

same-sex marriage. For purposes of coverage under the FEHB and FEDVIP, and for purposes of this 

document, such children are considered to be stepchildren. In order to enroll a stepchild in FEHB or 

FEDVIP coverage, you must first file a Declaration of Domestic Partnership with your employing office 

or retirement system. In addition, you must complete an SF 2809 form to first enroll or cover your 

stepchild under an existing enrollment. Please contact your agency’s human resources office or your 

retirement system for more information. 

When you cover your stepchild under an FEHB or FEDVIP enrollment, the fair market value of the 

stepchild's coverage, less any after-tax contributions you make toward the cost of that coverage, is 

taxable income to you, UNLESS your stepchild qualifies as a dependent as defined in Internal Revenue 

Code Section 152 (determined without regard to subsections (b)(1) (b)(2) and (d)(1)(B)) or a stepchild 

as defined under state law who, as of the end of the taxable year, has not attained age 27, whether or not 

that stepchild can be claimed as a dependent on your tax return. (See IRS guidance at 

http://www.irs.gov/uac/Answers-to-Frequently-Asked-Questions-for-Registered-Domestic-Partners-andIndividuals-in-Civil-Unions.) 

(Note: there are no tax consequences for an annuitant whose stepchild is covered under FEDVIP, 

because the entire premium is paid for by the annuitant with after-tax dollars.) 

This additional income, referred to as imputed income, is subject to applicable Federal income and/or 

employment taxes as well as state taxes. It will be reported on your annual Form W-2 or 1099-R. 

Because imputed income is calculated on the fair market value of coverage provided, it will be applied 

even if there is no additional monthly premium cost to you to cover your stepchild(ren) under your 

FEHB or FEDVIP plan. The amount of your imputed income depends upon the plan in which you are 

enrolled and the number of stepchildren covered who are not tax dependents. 

(Note: Imputed income does not affect calculations for your other benefits such as life insurance or 

retirement.)

If you are enrolled in premium conversion (i.e. making pre-tax employee contributions), the amount of 

your premium conversion allotment will not change. However, the fair market value amount that will be 

imputed to you will include that portion of your premium conversion allotment that is attributable to 

coverage of your stepchild(ren) who are not your tax dependents. 

Therefore, you will have imputed income and will be taxed on the amount your employing agency 

or retirement system contributes to provide FEHB and/or FEDVIP coverage for each of your
If you are covering your stepchild(ren) under an FEHB or FEDVIP plan, you must complete a 

Certification of Dependent Tax Status for Purposes of Coverage Under FEHB and FEDVIP 

(referred to below as a "Tax Certification") when the stepchild begins coverage. (Note: this 

requirement does not apply to annuitants who are enrolled in FEDVIP but not FEHB.) The Tax 

Certification will remain in effect from year to year, unless you file a new Tax Certification. Note, 

however, that the test for determining a stepchild's tax dependent status is an annual one, and it is up to 

you to determine every year, on an ongoing basis, whether the stepchild meets the applicable test for the 

entire year and to file a new Tax Certification if the stepchild's tax dependent status changes. 

Failure to submit a Tax Certification will result in taxation of the stepchild's coverage. 

Because the determination of whether a person is a tax dependent for FEHB and FEDVIP 

purposes turns on facts solely within your knowledge, your employing agency or retirement 

system cannot make this determination for you. This information is only a summary of the tax 

provisions governing the tax status of a stepchild for FEHB and FEDVIP purposes, and is not 

legal or tax advice. Due to the complexity of these tax rules and the potential impact of any 

imputed income you may incur, you should seek advice from a competent tax professional before 

certifying as to the tax status of the stepchild. You may also refer to www.irs.gov for information. 

For example, a worksheet from IRS publication 501 (available 

at: http://www.irs.gov/uac/Publication-501,-Exemptions,-Standard-Deduction,-and-FilingInformation-1) can be used for determining the support tests under Internal Revenue Code 

section 152. 

CERTIFICATION OF DEPENDENT TAX STATUS FOR PURPOSES OF COVERAGE 

UNDER FEHB AND FEDVIP

PRINTED Name of Employee/Annuitant

Last name First name M.I.

Declaration of Domestic Partnership on file? □ Y □ N 

PRINTED Name of Same-Sex Domestic Partner

Last name First name M.I.

Date Signed / /

stepchild(ren), unless you certify that they are your tax dependents for purposes of health 

coverage. Additionally, if you are enrolled in premium conversion, the portion of your premium 

conversion allotment attributable to coverage of your stepchild(ren) will be taxed unless you 

certify that they are your tax dependents for purposes of health coverage. 
I hereby certify that my stepchild(ren), who is/are the child(ren) of my same-sex domestic partner 

enrolled under my FEHB and/or FEDVIP plan(s), are (print full name and check appropriate 

box): 

PRINTED Name of Child

Last name First name M.I.

□ my tax dependent □ not my tax dependent 

□ covered under FEHB □ covered under FEDVIP 

PRINTED Name of Child

Last name First name M.I.

□ my tax dependent □

□ □

□ □

□ 

□ 

not my tax dependent 

 covered under FEHB covered under FEDVIP

PRINTED Name of Child

Last name First name M.I.

my tax dependent not my tax dependent 

covered under FEHB □ covered under FEDVIP

PRINTED Name of Child

Last name First name M.I.

my tax dependent □

□ □ 

not my tax dependent 

covered under FEHB covered under FEDVIP

* If more space is needed, please indicate on this form and attach additional pages. 

I understand that in order to qualify as a tax dependent for the purposes of coverage under FEHB and 

FEDVIP, my stepchild(ren) must meet requirements of the Internal Revenue Code. (Please consult with 

your tax advisor, and see http://www.irs.gov/ for more information.) 

I understand that I will be taxed on the fair market value of any FEHB and/or FEDVIP coverage 

provided to the children of my same-sex domestic partner, less any after-tax contributions I make toward 

the cost of such coverage, unless I certify that my stepchild(ren) are my dependent(s) as defined in 

Internal Revenue Code Section 152 (determined without regard to subsections (b)(1) (b)(2) and 

(d)(1)(B)) or stepchild(ren) as defined under state law who, as of the end of the taxable year, have not
 

 

attained age 27, whether or not the stepchild(ren) can be claimed as dependent(s) on your tax return. See 

attached for plan fair market value amounts.

I certify that the above information is true to the best of my knowledge and understand that false 

certification could result in legal consequences, including but not limited to tax penalties and possible 

disciplinary action by my employer. I will file a new Certification of Tax Status For Purposes of 

Coverage Under FEHB and FEDVIP with my agency human resources office or retirement system in 

the event of a change in the tax dependent status of any individual identified above. 

I understand that any change in such status may result in the retroactive application of taxes to amounts 

previously paid for FEHB and/or FEDVIP coverage during the year. 

I understand that until I return this form and indicate that my stepchild(ren) are tax dependents 

for health care purposes, the fair market value of coverage provided to my stepchild(ren) will be 

treated as additional taxable income to me. 

Employee’s Signature _______________________________________ 

Date Signed / /

Date Received / / (to be completed by employing office)