Spousal health care eligibility affidavit 2026

1. Click ‘Get Form’ to open the spousal health care eligibility affidavit in our editor.
2. Begin by entering your name and reference number at the top of the form. This identifies you as the employee submitting the affidavit.
3. Fill in your spouse's name and the last four digits of their Social Security Number. This information is crucial for verifying eligibility.
4. In Section A, select one of the options regarding your spouse's employment status. Ensure you check only one box that accurately reflects their situation.
5. If your spouse is employed without access to coverage or self-employed, proceed to Section B, which must be completed by their employer. If they have access to coverage, ensure that Section B is filled out accordingly.
6. Sign and date the affidavit at the bottom, ensuring both you and your spouse provide signatures where required.
7. Finally, submit the completed document to Hodges-Mace, LLC via fax or email as indicated on the form.

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