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8112UT (Rev 07-09) indd

8112UT (Rev 07-09) indd 2025

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The document is a Dependent Child Certification form that requires employees to provide personal and dependent information for health insurance coverage. It includes sections for employee details, child’s information, support verification, and legal requirements regarding medical child support orders. The form must be signed by the employee certifying the accuracy of the provided information.

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