Research Corporation of the University of Hawaiʻi

Research Corporation
of the University of Hawai‘i
Human Resources Department
RCUH Affidavit of Dependency For Tax Purposes
Whether or not your Domestic Partner qualifies as a dependent for tax purposes, this form must be submitted to the RCUH before your Domestic Partner can be enrolled. You will sign this form in one of two places, depending on your Domestic Partner’s status.
We, ____________________________, (the “Employee”) and, ____________________________, (the “Domestic Partner”), being duly sworn, under penalty of perjury say:
1. The Employee provides more than half of the Domestic Partner’s support for the year.
2. The Domestic Partner’s principal place of abode is the home of the Employee.
3. The Domestic Partner is a member of the Employee’s household.
4. The Domestic Partner is not a qualifying child of the Employee or any other person during the
taxable year.
5. The Domestic Partner is a citizen of _____________________________.
(Country)
If the answer to Question 5 was “United States”, skip to Question 9. If not, continue on to Question 6:
EXPLANATION: Under Section 152 of the Internal Revenue Code, as it pertains to health benefit plans, an individual may qualify as a “dependent” of an employee for tax purposes if: (a) the employee provides over one-half of the individual’s support for the employee’s taxable year, (b) the individual has the same principal place of abode as the employee for the entire taxable year, (c) the individual is a member of the employee’s household for the entire taxable year, and (d) the individual is a citizen or national of the UNITED STATES or a resident of the UNITED STATES or a country contiguous to the UNITED STATES
EXPLANATION: Under Section 7701(b) of the Internal Revenue Code, an alien is treated as a “resident” of the United States for tax purposes if such individual is lawfully admitted for permanent residence in the United States or meets the “substantial presence” test. To meet the “substantial presence” test, an individual must generally: (a) be present in the United States for at least 31 days during the current calendar year, and (b) the sum of the number of days on which the individual was present in the United States during the current calendar year and the 2 preceding calendar years (when multiplied by the applicable multipliers) equals or exceeds 183. The applicable multipliers are: 1 for the current year, 1/3 for the 1st preceding year, and 1/6 for the 2nd preceding year. The following individuals are not “residents” of the United States for tax purposes and, thus, can never be “dependents” for tax purposes:
 A foreign government-related individual temporarily present in the United States on a diplomatic or consular VISA, a full-time employee of an International organization, or a family member of such person.
 A teacher or trainee temporarily present in the United States.
 A student temporarily in the United States.
 A professional athlete temporarily in the United States to compete in a charitable sports event.
6. The Domestic Partner is currently a “resident” of ___________________________________.
(Country)
7. The Domestic Partner is currently lawfully present in the United States under the following type of VISA: ________________________________.
RCUH Form B-16
Created 05/18/2012, Rev. 06/17/2014, 11/19/2014, 03/30/2016
RE: Affidavit of Dependency for Tax Purposes Page 2 of 4
If the type of VISA is “permanent resident” skip to Question 9. If not, answer the following questions:
8. The Domestic Partner meets the “substantial presence” test as the actual number of days the Domestic Partner has been lawfully present in the United States during the current year and the 2 preceding years is:
___________ (# of days in the USA, current year) x 1 = ___________ (# of days in the USA, 1st preceding year) x 1/3 = ___________ (# of days in the USA, 2nd preceding year) x 1/6 =
Total of above (must equal or exceed 183) =
____________
____________
____________
____________
EXPLANATION: Under Section 152 (f)(3) of the Internal Revenue Code provides that an individual is not a member of the taxpayer’s household if at any time during the taxable year of the taxpayer, the relationship between such individual and the taxpayer is a violation of local law.
9. Our state of permanent residence for purposes of the test required by Section 152 (b) (5) of the Internal Revenue Code is ________________.
(State)
10. We understand that if the Domestic Partner is not a “dependent” of the Employee, we may incur various tax liabilities in connection with obtaining health care coverage for the Domestic Partner. We therefore agree to notify the RCUH within ten (10) days if there is any change in the Domestic Partner’s status as a “dependent” of the Employee. In addition, we shall indemnify and hold the RCUH harmless for any taxes, tax related penalties, or interest imposed upon the RCUH as a result of providing Domestic Partner coverage to us, including any taxes, tax related penalties, or interest imposed as a result of our taking the position the Domestic Partner is a “dependent” of the Employee for tax purposes.
11. We understand that RCUH is relying on the information and representations contained in this Affidavit. We further understand that legal action may be brought against the Employee and/or Domestic Partner for any losses, financial or otherwise, due to false statements contained in this Affidavit and related forms or for failure to timely notify RCUH of changed circumstances as required. We agree that each of the signers of this form is jointly and severally liable for any damages incurred by RCUH as a result of any false statements or failure to timely notify RCUH of changed circumstances as required, including, but not limited to, reasonable attorneys’ fees and other legal expenses. We also understand that providing false statements or failure to timely notify RCUH of changed circumstances as required may lead to disciplinary actions against the Employee, up to and including discharge from employment
_________________________________________________________________________________
RCUH Form B-16
Created 05/18/2012, Rev. 06/17/2014, 11/19/2014, 03/30/2016
RE: Affidavit of Dependency for Tax Purposes Page 3 of 4
If your domestic partner is NOT a qualified dependent, STOP HERE, print your name, sign, and date. Return this form to RCUH Human Resources Department via scan/email to [email protected] or fax to (808) 956-5022. If your dependent is a qualified dependent, please continue to the next page.
I affirm that under penalty of perjury under the laws of the State of Hawaii, the statements in this affidavit are true to the best of my knowledge. I have read this document and have determined that my domestic partner is NOT qualified as a dependent under Section 152 of the Internal Revenue Code as described above.
Name (Print): ____________________________________________
Signature _______________________________________________ Date: _________________
RCUH Form B-16
Created 05/18/2012, Rev. 06/17/2014, 11/19/2014, 03/30/2016
RE: Affidavit of Dependency for Tax Purposes Page 4 of 4
This section to be completed in the presence of a NOTARY PUBLIC
Each of us affirms, under penalty of perjury under the laws of the State of Hawaii, that we are the respective undersigned signatories, the statements in this affidavit are true to the best of our knowledge, and this affidavit and related application instruments are the free act and deed of each of us.
___________________________________ Employee’s Signature
___________________________________ Print Employee’s Name
___________________________________ Employee’s SS#
_____________________________________ Domestic Partner’s Signature
_____________________________________ Print Domestic Partner’s Name
_____________________________________ Domestic Partner’s SS#
Employee/Domestic Partner Address: ______________________________________________ ______________________________________________ ______________________________________________
Subscribed and sworn to before me
This _____ day of ______________, 20 ___.
_______________________________________ Signature of Notary Public
_______________________________________ Notary Public – State of Hawaii (Print name)
My commission expires: ________________
Provide Notary Seal below:
Subscribed and sworn to before me
This _____ day of ______________, 20 ___.
_______________________________________ Signature of Notary Public
_______________________________________ Notary Public – State of Hawaii (Print name)
My commission expires: ________________
Provide Notary Seal below:
RCUH Form B-16
Created 05/18/2012, Rev. 06/17/2014, 11/19/2014, 03/30/2016