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PDF Declaration of Legal Ward as Eligible Dependent 2026

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The document is Form 3028, a Declaration of Legal Ward as Eligible Dependent for Triad Health Plan subscribers. It requires subscribers to certify that their enrolled dependents meet IRS criteria for health insurance benefits, including living together, citizenship status, and financial support. Subscribers must notify the LANL Benefits Office of any changes in circumstances and understand the legal implications of false certification. The form emphasizes confidentiality and advises consulting a personal tax advisor for tax-related questions.

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Click ‘Get Form’ to open the PDF Declaration of Legal Ward as Eligible Dependent in our platform.
Begin by filling in your personal information as the Health Insurance Subscriber. Enter your last name, first name, Z number, and social security number in the designated fields.
Next, provide details for each enrolled dependent. Complete a separate form for each dependent by entering their last name, first name, Z number, and social security number.
In the Declaration section, read through the requirements carefully. Confirm that you meet all IRS criteria for your dependent's eligibility by checking the appropriate boxes.
Sign and date the declaration at the bottom of the form to certify that all information is accurate and complete.
Finally, save your completed form using our platform’s save feature and return it to the LANL Benefits Office via fax or email as instructed.

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