Author: gfaivre
Last saved by: Campbell, Constance
Company: CA Department of Personnel Administration

Insert Departmental Letterhead

[Date]

[Employee Name]
[Address] 
[City, State, Zip]

RE:  Annual Recertification of Dependents in a Parent-Child Relationship (PCR) Enrolled in State-Sponsored Dental and/or Vision Benefits

Dear [Employee Name]:

The certification of the following Parent-Child Relationship dependent(s) enrolled in the state’s dental and/or vision benefits will expire on [insert last day of the month of the employee’s birth month]. Recertification of a Parent-Child Relationship must be completed on an annual basis.

Enrolled PCR Dependent(s) | Date of Birth | Dental or Vision Plan

To continue enrollment of your PCR dependent(s) in the state’s dental and/or vision program, you must complete and submit a new signed and dated Affidavit of Parent-Child Relationship (CalHR Form 025), Dependent Eligibility Verification Checklist (CalHR Form 781), and required documents to substantiate a continuance of the parent-child relationship to your departmental Human Resources (HR) Office by [insert last day of the month of the employee’s birth month].  The required documents to substantiate your relationship with the PCR dependent(s) are outlined on the Checklist.
 
The Affidavit of Parent-Child Relationship and Dependent Eligibility Verification Checklist forms are available on the California Department of Human Resources’ website at www.calhr.ca.gov or you may obtain a copy of these forms from your HR Office.
 
If you do not provide the required documents to your HR Office or are unable to substantiate your relationship with the PCR dependent(s), then the dependent(s) will be removed from coverage.  Dependents removed from coverage are eligible for and will be offered Federal Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage.
 
Please contact your HR Office at XXX-XXX-XXXX with questions about this letter or the annual recertification process.