Dependent Eligibility Verification Process

Budco will mail you a dependent eligibility verification packet about two to three weeks after you enroll your dependent in health care coverage. The packet will contain detailed information and instructions on what documentation must be provided, how to submit your documentation, and your submission deadline. You will have about 30 days from the date of the packet to respond directly to Budco. If you do not respond by the deadline specified in your packet, your dependent will be dropped from coverage effective the first of the month following the deadline.

If your dependent is dropped, your next opportunity to enroll the dependent will be during the Open Enrollment period in the fall, or at the time you experience a qualified family status change event.

• Mark out confidential information. You may choose to mark out all financial information and the first five digits of all Social Security numbers. Only the last four digits of Social Security numbers are needed. See the attached for an example of how to mark up and submit a copy of your tax returns.
• Provide copies—not originals—of official documents. For example, for a marriage certificate, a copy of the file stamped “marriage certificate” issued by the state or locality is needed. For court documents, a copy of the document that is signed and stamped by the court is needed. Documentation with missing signatures, dates, seals or other needed and applicable information will not be accepted.
• Birth certificates must list parents’ names. If you have the “short form” birth certificate, which does not include the parents’ names, you will be required to obtain the long form birth certificate. The following websites can help you obtain the long form birth certificate. Please allow the necessary time to receive and submit your documentation:
  • National Center for Health Statistics website: http://www.cdc.gov/nchs/w2w.htm (click the appropriate state for information)
  • Vitalchek’s website: www.vitalchek.com
  • http://travel.state.gov/passport/get/first/first_825.html
• All non-English documents must be provided with an official translation and bear the stamp and mark of a registered translator. You may contact a local college, university or translator services company for assistance. You or a family member cannot translate the documents. If you send non-English documents that have not been translated, your dependents’ status will be marked as incomplete until the official translation is received.

Couples married before the current calendar year:

Choose ONE of the options below and submit the appropriate document(s):

1. Filed federal or state tax return for the current tax year
   • Only submit the first page of the return. This page could come from your 1040 form, e-File confirmation page, tax preparer’s summary, federal return recap, or Telefile.
   • Mark out all financial information and the first five digits of all Social Security numbers.
   • If you file as “married filing separately,” your spouse’s name must appear on the tax form on the line provided after the “married filing separately” status (or vice versa).
   • See below for an example of how to mark up and submit your tax return.
2. Marriage certificate AND proof of joint ownership*
3. Military ID AND proof of joint ownership*
4. Printout of online marriage record AND proof of joint ownership*
5. Previous years filed federal or state tax return AND documentation of the filing of extension Form 4868 for the current tax year return. See notes in No.1 above.

*Proof of joint ownership documents must include both the employee and spouse’s names on the document. You can send any one of the following documents:

• • Mortgage statement, credit card statement, car note, bank statement, school taxes, home equity loan, Rent-A-Center statement, or utility bills dated from any time in the last three months.
  • Rental/lease agreement, property appraisals from the city, county or state for tax purposes or property tax document, school taxes, deed, or bankruptcy paperwork dated from any time in the last 12 months.
  • Automobile registration that is currently in effect and shows joint ownership.
  • Auto insurance statement— must show both the employee and spouse listed on the
    policy and must be currently in effect.
  • Homeowner’s insurance statement—must list the employee and spouse and be currently in effect.

Couples married within the current calendar year:
Submit a copy of the marriage certificate only.

Choose ONE of the options below and submit the appropriate document(s):

1. Provide a civil union certificate or proof of domestic partner registration with the appropriate government agency or municipality AND submit one of the items listed below as proof of joint ownership*.
2. Complete the McClatchy Company’s domestic partner affidavit AND provide one of the joint ownership items listed below dated at least 12 months ago AND one of the items listed below as proof of current joint ownership*.

*Proof of joint ownership documents must include both the employee’s and domestic partner’s names on the document.

• Mortgage statement, credit card statement, car note, bank statement, school taxes, home
  equity loan, Rent-A-Center statement, or utility bills dated from any time in the last three
  months.
• Rental/lease agreement, property appraisals from the city, county or state for tax
  purposes or property tax document, school taxes, deed, or bankruptcy paperwork dated
  from any time in the last 12 months.
• Automobile registration that is currently in effect and shows joint ownership.
• Auto insurance statement— must show both the employee and domestic partner listed on
  the policy and must be currently in effect.
• Homeowner’s insurance statement—must list the employee and domestic partner and be currently in effect.
• Power of Attorney for Healthcare and/or Property
• Joint wills
• Safe Deposit box signatures

You must submit ONE of the following:

1. Birth certificate showing the child’s parents.
2. Official hospital record showing the child’s parents.
3. Official paternity test showing the child’s parents.
4. Verification of Birth Facts or Certification of Birth Facts showing the child’s parents: The document must include signature and date from hospital representative or state information.
5. Domestic adoptions: court-approved adoption papers (with signature or seal), Adoption
   Placement Agreement or Petition for Adoption.
6. Foreign adoptions: foreign country adoption papers (with official English translation from a registered translator) or Adoption Placement Agreements (with English translation from a registered translator).
7. Report of Birth Abroad of a citizen of the United States of America, issued by the Department of State, showing the child’s parents. (The Certificate of Birth Abroad, also issued by the Department of State, is NOT acceptable unless it lists the parents’ names.)
8. Divorce decree that lists children born to the marriage.
9. State Affidavit of Parentage or Paternity (or like form) that acknowledges the child’s father. This form must have some indication that it was filed with the state or with the court.
10. Court approved child support order which shows all of the following:
    • Indicating the child’s parents
    • The name of the dependent covered by the agreement
    • Signatures or court seal/stamp or case number
11. Court-awarded legal guardianship or court custody papers which show all of the following:
    • Indicating legal custody by the courts
    • Indicating the child’s legal guardian or custodial adult
    • The name of the dependent covered by the agreement
    • Signatures or court seal/stamp or case number
12. Legal documentation of a foster child showing:
    • You have been granted foster care of a child under state law.
    • You, your spouse or domestic partner are the child’s foster parent.
    • The name of the dependent covered by the agreement
    • Must be currently in effect

Choose ONE of the options below and submit the appropriate document(s):

1. Current tax year filed federal or state tax return showing the child as a dependent
   • Please note:
     • Only submit the first page of the return. This page come from your 1040 form, tax preparer’s summary or federal return recap.
     • Mark out all financial information and you may choose to mark out the first five digits of all Social Security numbers.
     • See the attached for an example of how to mark up and submit a copy of your tax return.
2. Previous tax year filed federal or state tax return showing the child as a dependent AND documentation of the filing extension Form 4868 for the 2010 tax return. (See notes in No. 1 above)
3. Spouse or domestic partner’s current year filed federal or state tax return showing the child as a dependent: Note the address on the tax return must match the employee’s
   address of record and marital or domestic partner status must be proven. (See notes in No. 1 above)
4. If the child is claimed as an exemption during alternating tax years due to divorce, submit the previous year filed federal or state tax return showing the child as a dependent AND your or your spouse or domestic partner’s divorce decree stating that the dependent is claimed during alternating tax years.
5. Employee, spouse or domestic partner’s divorce decree or court order paperwork or child support order showing your responsibilities.
   • Divorce decree/court order agreement must include:
     • First page of agreement listing you as either the petitioner (plaintiff) or the respondent (defendant).
     • Names of the children covered by the agreement.
     • Name of the person responsible for providing health/medical benefits or financial support.
     • Indication that the decree has been filed (such as a stamp, judge’s signature, or case number).
       Note: If the divorce decree does not list the children’s names, you must also provide copies of
       birth certificates (or hospital records, etc.) showing both the petitioner and respondent as the
       children’s parents.
6. Eight months worth of canceled checks showing a consistent pattern of support or eight months worth of bank or credit card statements with corresponding receipts, such as child support.
7. SSI or SSDI Statement (1099)
8. Current filed Tax Return Transcript only showing the last four digits of the SSN of the child
9. Current filed Earned Income Credit (EIC) tax form listing the name of the child
10. Proof of payment for the dependent to live in a facility
11. Form 2441 – Child/Dependent Care Expense listing the child

When submitting your tax returns, please mark out all personal information, including the first five digits of all Social Security numbers. Specific information that needs to be shown includes:

1.  Your full name and the full name of your spouse
2. The last four digits of the Social Security number for yourself and your spouse
3. Your full address
4. Filing status
5. Your dependent’s full name
6. The last four digits of the Social Security number for your dependent
7. The relationship of your dependent

Please see example below: