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The Florida KidCare Employment Statement is a crucial document in the application process for KidCare health insurance. This form must be completed by each employer providing income to a family member applying for KidCare. To streamline the process, applicants can skip this requirement if they submit recent pay stubs. The form consists of two main sections: Section A is for the employee, who must provide their Family Account Number, authorize the release of employment information, and sign the document. Section B is dedicated to the employer, who is asked to provide essential details regarding the employee's work hours, payment frequency, gross pay rate, and any variations in hours or pay. Employers must ensure the accuracy of the information provided, as any false statements can lead to serious consequences. Once completed, the form must be sent to Florida KidCare at the designated address in Tallahassee, ensuring that the application process continues smoothly and efficiently.

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FLORIDA KIDCARE

EMPLOYMENT STATEMENT

General Directions: Copy this form and have it completed by each employer that provides income to a family member on the KidCare application. If you provide recent pay stubs, you do not need this form completed.

Complete Section A and submit to employer for completion. Completed form must be returned to Florida KidCare, P O Box 591, Tallahassee, Florida, 32302-0591.

Section A – To Be Completed by Employee

Family Account Number: __________________________

I authorize the release of employment information for the purpose of determining KidCare eligibility.

Employee Signature: _________________________________ Date: ___________________

Employee Name: _____________________________ Employee SSN: __________________

(please print)

Section B – To Be Completed by Employer

Directions: This information is needed to help determine eligibility for KidCare Health Insurance. Please assist us by answering the following questions for the employee listed above, and returning this form to: Florida KidCare, PO Box 591, Tallahassee, Florida, 32302-0591.

(1) Number of Hours Worked Per Week: _______

Number of Days Worked Per Week: _______

(2) How often is the employee paid:

_ Daily

_ Weekly _ Bi-Weekly _ Monthly

_ Twice Monthly

_ Other: _______________

 

(explain)

(3) Rate of gross pay: $ ___________ per _________________

_ Other: _______________

Hour/Day/Week/etc.

(explain)

(4)If hours or rate of pay has varied in the above period, please state why (include tip information here): ________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

(5)Employer Statement: What I have written on this form is true to the best of my knowledge. I know that if I give false information on purpose, I may be subject to prosecution for fraud.

_____________________________________

______________________________________

Signature of Employer

Employer’s Title

_____________________________________

(________) ___________________________

Name of Employer (please print)

Employer’s Telephone Number

_____________________________________

_____________________________________

Name of Business

Date Completed

_____________________________________

_____________________________________

Business Address

City, State, Zip

 

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Form Specifications

Fact Name Description
Purpose of the Form This form is used to gather employment information necessary for determining eligibility for Florida KidCare health insurance.
Who Completes It Each employer providing income to a family member on the KidCare application must complete this form.
Submission Process The completed form must be returned to Florida KidCare at P.O. Box 591, Tallahassee, Florida, 32302-0591.
Section A Section A is to be completed by the employee, including their family account number, signature, and personal information.
Section B Section B is for the employer to fill out, providing details about the employee's work hours, pay frequency, and gross pay rate.
Legal Implications Providing false information on this form can lead to prosecution for fraud, as stated in the employer's statement.
Governing Laws The Florida KidCare program operates under Florida Statutes, specifically Chapter 409.818, which outlines eligibility and application processes.
Pay Stub Exception If recent pay stubs are provided, the completion of this form is not necessary, streamlining the application process.

Florida Kidcare: Usage Guidelines

To complete the Florida KidCare form, follow the steps outlined below. Each employer must fill out a separate form for each family member applying for KidCare, unless recent pay stubs are provided. After filling out the necessary sections, submit the completed form to the specified address.

  1. Obtain a copy of the Florida KidCare Employment Statement form.
  2. In Section A, enter the Family Account Number.
  3. Sign the authorization for the release of employment information.
  4. Fill in your name and Social Security Number (SSN) in the designated areas.
  5. Submit Section A to your employer for completion.
  6. Instruct your employer to fill out Section B with the required information, including hours worked, pay frequency, and gross pay rate.
  7. Ensure your employer includes a statement confirming the accuracy of the information provided.
  8. Have your employer sign and print their name, title, and contact information.
  9. Make sure your employer includes the business name, address, and date completed.
  10. Return the completed form to Florida KidCare at the provided address: P O Box 591, Tallahassee, Florida, 32302-0591.

Your Questions, Answered

What is the purpose of the Florida KidCare Employment Statement?

The Florida KidCare Employment Statement is a form designed to gather employment information for family members applying for KidCare health insurance. It helps determine eligibility based on income and work status. If you provide recent pay stubs, you do not need to complete this form.

Who needs to fill out the Florida KidCare Employment Statement?

What information is required from the employee on the form?

What details must the employer provide in Section B?

Where should the completed form be sent?

What happens if the employer provides false information?

Can I submit recent pay stubs instead of the Employment Statement?

How can I ensure that my application is processed quickly?

Common mistakes

  1. Not providing a Family Account Number. This number is crucial for identifying your application. Without it, processing delays can occur.

  2. Failing to sign the form. Both the employee and the employer must provide their signatures. A missing signature can lead to rejection of the application.

  3. Leaving out the Employee SSN. This number is essential for verifying the identity of the employee. Omitting it can slow down the eligibility process.

  4. Not providing accurate information about hours worked. Ensure that the number of hours and days worked per week is filled out correctly. Inaccurate details can lead to confusion.

  5. Choosing the wrong pay frequency. Select the correct option from daily, weekly, bi-weekly, or monthly. Incorrect selections can complicate income calculations.

  6. Neglecting to explain variations in pay or hours worked. If there are changes, detail them in the provided space. Lack of explanation can raise red flags.

  7. Not submitting the form to the correct address. Always double-check that you send it to Florida KidCare, PO Box 591, Tallahassee, Florida, 32302-0591. Misaddressed forms can get lost.

Documents used along the form

The Florida KidCare program provides health insurance coverage for children in families with limited income. To apply for this program, several forms and documents may be required in addition to the Florida KidCare Employment Statement. Below is a list of commonly used documents that support the application process.

  • Florida KidCare Application Form: This is the primary document used to apply for KidCare benefits. It collects essential information about the family, including household income and the number of children requiring coverage.
  • Proof of Income: Recent pay stubs, tax returns, or other documentation that verifies the family's income. This information is crucial for determining eligibility for KidCare.
  • Social Security Numbers: The Social Security numbers of all family members applying for KidCare are required. This information helps to verify identity and eligibility.
  • Birth Certificates: Copies of birth certificates for all children applying for coverage may be requested. This document establishes the age and identity of the children.
  • Verification of Residency: Documentation that proves the family's residency in Florida. This could include utility bills, lease agreements, or other official documents that show the family's address.
  • Health Insurance Information: If the family has existing health insurance, details about that coverage may be required. This information helps determine the need for KidCare coverage.
  • Authorization Forms: These forms may be necessary to allow Florida KidCare to obtain information from other agencies or employers. They ensure that the application process can proceed smoothly.

Gathering these documents can help streamline the application process for Florida KidCare. Each document plays a vital role in verifying eligibility and ensuring that children receive the necessary health coverage.

Similar forms

The Florida KidCare Employment Statement is an important document used to determine eligibility for health insurance for children. It shares similarities with several other documents that serve similar purposes in various contexts. Below are four documents that resemble the Florida KidCare form:

  • W-2 Form: This form is provided by employers to report annual wages and taxes withheld for employees. Like the KidCare form, it requires information about an employee's income, making it essential for verifying financial eligibility for various programs.
  • Pay Stub: A pay stub details an employee's earnings for a specific pay period, including deductions. Similar to the KidCare form, it provides crucial information about income and hours worked, helping to assess eligibility for assistance programs.
  • Unemployment Benefits Application: Individuals seeking unemployment benefits must complete an application that includes employment history and income details. This document, like the KidCare form, aims to establish eligibility based on financial need and work history.
  • Medicaid Application: The Medicaid application requires detailed financial information to determine eligibility for health coverage. Much like the Florida KidCare form, it seeks to gather necessary data about income and family circumstances to assess qualification for health services.

Dos and Don'ts

When filling out the Florida KidCare form, there are important guidelines to follow. Here’s a list of what you should and shouldn't do:

  • Do ensure you copy the form if multiple employers are involved.
  • Do complete Section A before giving the form to your employer.
  • Do provide accurate information about your employment.
  • Do sign and date the form where required.
  • Do submit the completed form to the correct address: Florida KidCare, P O Box 591, Tallahassee, Florida, 32302-0591.
  • Don't leave any sections blank; fill in all required fields.
  • Don't provide false information; it can lead to serious consequences.
  • Don't forget to include your family account number.
  • Don't submit the form without your employer’s completion and signature.

Misconceptions

Understanding the Florida KidCare form can be challenging, and several misconceptions often arise. Here are seven common misunderstandings about the form and the process involved:

  • Pay Stubs are Required for Everyone: Many believe that the Florida KidCare form must be completed by employers regardless of whether pay stubs are provided. In reality, if recent pay stubs are submitted, the form is not necessary.
  • Only One Employer Needs to Complete the Form: Some think that only the primary employer needs to fill out the form. However, every employer providing income must complete a separate form for each family member on the application.
  • The Form Can Be Submitted Anytime: There is a misconception that the form can be submitted at any time. It must be returned promptly to avoid delays in determining eligibility for KidCare health insurance.
  • Eligibility is Guaranteed Once the Form is Submitted: Many assume that submitting the form guarantees KidCare eligibility. Eligibility is determined based on various factors, including income and family size, not just the completion of the form.
  • All Information is Confidential: While personal information is protected, some people believe it is completely confidential. It's important to know that the information may be shared with relevant authorities to verify eligibility.
  • Employers Can Refuse to Complete the Form: Some think that employers have the right to refuse to fill out the form. In fact, employers are legally obligated to provide accurate information when requested for eligibility determination.
  • Only Full-Time Employees Need to Complete the Form: There is a belief that only full-time employees need to provide this information. However, all employees, regardless of hours worked, must have the form completed if they contribute to the household income.

By clarifying these misconceptions, families can navigate the Florida KidCare application process more effectively and ensure they meet all necessary requirements.

Key takeaways

When filling out and using the Florida KidCare form, it is essential to follow specific guidelines to ensure a smooth application process. Here are key takeaways to keep in mind:

  • Complete Section A: As the employee, fill out Section A of the form before submitting it to your employer.
  • Authorization: By signing Section A, you authorize the release of your employment information, which is necessary for determining eligibility.
  • Employer's Role: The employer must complete Section B, providing accurate details about your employment.
  • Submission Address: Ensure that the completed form is sent to Florida KidCare at P.O. Box 591, Tallahassee, Florida, 32302-0591.
  • Pay Stubs Alternative: If you provide recent pay stubs, you do not need to have this form completed by your employer.
  • Information Required: Employers will need to provide information such as hours worked, pay frequency, and gross pay rate.
  • Accuracy is Crucial: Employers must attest that the information provided is true to the best of their knowledge to avoid potential legal issues.
  • Contact Information: Ensure that your employer includes their contact information, including their name, title, and business address.
  • Timeliness: Submit the form promptly to avoid delays in the eligibility determination process.

Following these guidelines will help ensure that your application for Florida KidCare is processed efficiently. If you have any questions, consider reaching out to Florida KidCare for assistance.