You are completing a life event and you received notification from CalPERS that you must complete this form. To start a Life Event, go to: Life Event Quick-start Guide.

Complete this form only if you receive a notification from CalPERS that this form is required.

This form should be printed, completed and submitted in person to the campus benefits office only when you have been notified by CalPERS of the need to verify your dependent(s)’ eligibility for benefits.  Dependents include your spouse, registered domestic partner, natural born child, adopted child, stepchild, or the child of your registered domestic partner. This dependent verification of benefits eligibility process is conducted once every three years for most dependents.

Step 1: Click Dependent Re-verification Affidavit.

Step 2: Read the form carefully.

Step 3: Verify the dependent information in Section B:

• Dependent Benef
• Dependent EffDt
• Dependent Name
• Relationship
• Date of Birth

Step 4: Click the check box to acknowledge the statement.

Step 5: Optional: click Print PDF to print a PDF version of the form.

Step 6: Click Save.

Return to the Life Event Quick-start Guide.