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Get Domestic Partner Dependent Certification - The California State ...

Er imputed tax liability status for domestic partnership (DP) health-related benefits. (Currently only health and dental benefits are subject to DP imputed tax liability.) Please check the appropriate statement and complete the employee portion of the form. This is to certify, under the penalty of perjury, that effective with tax year , I, , am claiming my domestic partner, , as my dependent for the purposes of my federal in.

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