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State of Texas Employee Benefits


State of Texas Employee Benefits document sample

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									                                   Employee Educational Benefits Program
                                          Dependent Certification
                                                 Texas State Technical College

          Print Dependent's Name                      Dependent's Colleague ID#                 Semester & Year (e.g. Fall 2009)

To be ELIGIBLE to receive dependent educational benefits, a person must meet one of the
following criteria for an eligible dependent as established by the Employees Retirement System of
Texas (ERS):

     ◊   Your spouse
     ◊   Your natural or adopted child
     ◊   A stepchild whose primary residence is with you
     ◊   A foster child whose primary residence is with you
     ◊   Your grandchild who is claimed as a dependent on your federal income tax return
     ◊   A child for whom you are the legal guardian, whose primary residence is with you
     ◊   A child with whom you have established a parent-child relationship, whose primary residence is with you
     ◊   A child over the age of 25 who is mentally or physically incapacitated, regardless of age, and who lives with, or
         whose care is provided by, you on a regular basis, and who is mentally retarded or physically handicapped to such
         an extent as to be dependent upon you for care or support.

A person is INELIGIBLE to be considered your dependent if one or more of the following is true:

     ◊   The person is over the age of 25 (excluding your spouse)
     ◊   The stepchild or foster child no longer lives at home
     ◊   The person is married (regardless of age)
     ◊   The person is your ex-spouse

I certify that
is eligible for Employee Educational Benefits based on the ERS criteria listed above. I also certify the aforementioned
person does not meet any of the other conditions listed above that would render him/her ineligible for these benefits.

I certify that I am a benefits-eligible employee of TSTC. I understand that I will need to recertify this person's eligibility
each semester. If I fail to submit a new Dependent Certification form, I understand that this person will not be eligible for
the Employee Educational Benefits Program for that semester.

           Print Employee's Name                      Employee's Colleague ID#                       Employee's Hire Date

                                             Employee's Signature                 Date Signed

TSTC-0-HR-039 (08-07) TSTC-2-HR-037 (08/26/09)

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