Ps 457 2025

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The document is a form from the New York State Department of Civil Service that must be completed by an enrollee applying for health insurance coverage for a dependent child who is not their biological, adopted, or stepchild. It outlines eligibility criteria, including residency and support requirements, and provides instructions for documentation needed to prove dependency. The form also includes legal disclaimers regarding the accuracy of information provided and potential penalties for fraudulent claims.

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