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Certificate of Dependency Form

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Non-Prejudicial Agreement (DWC-20 06/2014)

RI Department of Labor and Training, Division of Workers' Compensation

PO Box 20190, Cranston, RI 02920-0942

www.dlt.ri.gov/wc | Phone 401-462-8100 | Fax 401-462-8105

Claim Administrator Claim Number

Employee Information

SSN or ID

Name

Address

City, State Zip

Date of Birth

Employer Information

FEIN

Business Name

Address

City, State Zip

Phone

Insurer Information

FEIN

Business Name

Address

City, State Zip

Phone

Claim Administrator Information (Adjusting Company)

FEIN

Business Name

Address

City, State Zip

Phone

Injury Information

Date of Injury

Place where injury occurred

Injured body part & nature of injury

Rate Information

Employee's Marital Status

Number of Exemptions (self, spouse & children)

Number of Dependents (children & nonworking spouse)

Spendable Base Wage

Total Average Weekly Wage

Weekly Dependency Rate

Base Compensation Rate

Total Weekly Rate

Disability Information

First Payment Issue Date

First Date of Disability

Temporary Total Start Date

Temporary Partial Start Date

Permanent Total Start Date

Death Benefits Start Date

Date of Death

Death Benefits Paid to

Other information

Does the employee have other employers?

Is this a recurrence of a previous injury?

Previous disability end date

Did the employee work 26 weeks or more before this recurrence?

Signature

Claims Adjuster Signature

Printed Name

Date

Notice to Employees Receiving Worker's Compensation Benefits

ATTENTION: The employer and insurer are NOT accepting legal responsibility for your work injury. You have two (2) years to file a petition at the Workers' Compensation Court to establish liability.

ATENCION: El empleador y la compañía aseguradora NO se hacen legalmente responsables de su lesión en el trabajo. Tiene dos (2) años para entablar una demanda en el Tribunal de Compensación Laboral para establecer la responsabilidad.

DWC-20 06/2014

Page 1 / 2

RIGL § 28-35-8 requires the insurer to file a Non-Prejudicial Agreement with The Department of Labor and Training (DLT) when indemnity benefits are paid voluntarily without liability.

A Wage Statement (DWC-03) and Certificate of Dependency Status (DWC-04) must be submitted as part of the agreement.

A copy of the agreement must also be sent to the employee and his or her attorney.

As of March 1, 2015, the insurer must also submit an electronic Subsequent Report of Injury to DLT when benefits begin.

Claim Administrator Claim Number

Provide the claim number or file identification number for the company handling the claim: the insurer, self-insured employer or third party administrator.

Employee information

SSN or ID: Provide at least the last 4 digits of the employee’s social security number or the employee ID number assigned by DLT.

Name: enter the employee’s first name, middle initial and last name.

Address: give the employee’s mailing address, city, state and zip.

Date of birth: enter the employee’s date of birth.

Employer information

Provide the employer’s Federal Employer Identification Number, employer business name, employer business mailing address and phone number.

Insurer information

Provide the information for the licensed insurer named on the workers’ compensation policy or the self-insured employer’s name.

Claim Administrator information

Supply information for the company handling the claim. Provide the claim administrator business name, mailing address, and phone number.

Injury Information

Date of injury: enter the date of the injury or start of illness.

Place where injury occurred: enter the city and state where the injury occurred.

Injured body part & nature of injury: list the nature of each injury and the employee’s injured body parts.

Rate Information

Employee’s marital status: check single if the employee is unmarried, divorced or widowed. Check married if the employee is married or separated.

Number of Dependents: enter the number of employee’s dependents including non-working spouse and dependent children.

Number of Exemptions: enter the maximum number of exemptions the employee can claim for tax purposes.

Total Average Weekly Wage: enter the amount of the total average weekly wage (AWW) as calculated on the Wage Statement (DWC-03).

Spendable Base Wage: calculate the Spendable Base Wage using the formulas or tables on the DLT web site.

Base Compensation Rate: Multiply the Spendable Base Wage by 75% to calculate the base compensation rate.

Weekly Dependency Rate: Enter the total weekly amount of dependency allowance, up to 80% of total AWW.

Total Weekly Rate: Enter the total weekly compensation rate including dependency.

Disability Information

First Payment Issue Date: Enter the date the first indemnity payment was issued for this disability period.

First Date of Disability: Enter the start date of the first disability period for this injury including the waiting period.

Temporary Total Start Date: Enter the first date the employee is owed temporary total disability benefits for this period of disability.

Temporary Partial Start Date: Enter the first date the employee is owed temporary partial disability benefits for this period of disability.

Death Benefits Start Date: Enter the first date the employee’s survivors are due death benefits.

Date of Death: If the employee has died, enter the date of death.

Death Benefits Paid to: Enter the name of the primary survivor receiving death benefits.

Other Information

Does the employee have other employers? Check yes or no.

Is this a recurrence of a previous injury? Check yes or no.

Previous disability end date: enter the last date of the previous disability to show if 26 weeks have passed.

Did the employee work 26 weeks or more before this recurrence? Check yes or no.

Signature Block. The claim adjuster must sign this document, print name and date the form.

Send the document to the employee, the employee’s attorney and the DLT within 10 days of the first payment issue date.

Revised 12/12/2016

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What the Certificate of Dependency Form Is

The Certificate of Dependency Form is a formal declaration used to verify that an individual qualifies as a dependent of another person for administrative, tax, benefit, or program enrollment purposes. It records identity, relationship, residency, financial support, and custodial status where relevant. Organizations such as employers, insurers, educational institutions, and government agencies rely on the certificate to confirm eligibility and to preserve a clear record of the facts supporting dependent claims. Required fields and supporting documents vary by program and jurisdiction.

Stepwise process to complete the form

Follow these steps to complete and validate a Certificate of Dependency Form accurately and efficiently.

  • 01
    Gather Documents: Collect IDs, birth certificates, custody orders, and proof of financial support.
  • 02
    Complete Form: Enter all fields using MM/DD/YYYY and full legal names.
  • 03
    Attach Evidence: Upload legible scans or certified copies of each supporting document.
  • 04
    Sign & Notarize: Sign, obtain notary or RON if required, and retain copies.

Common questions about completing and submitting the form

Answers to common questions about completing, signing, and submitting a Certificate of Dependency Form, including e-signing and notarization options.


Need help? Contact support

Who commonly completes and accepts this certificate

Typical users of the Certificate of Dependency Form include sponsors, parents or guardians, employers, insurers, and government or educational agencies that verify dependent eligibility.

  • Parents and legal guardians completing dependent declarations for benefits or school enrollment.
  • Employers verifying coverage eligibility for health insurance or tax withholding purposes.
  • Government agencies and insurers requiring proof for program eligibility or dependent benefits.

Use the following sections for field-level guidance, submission methods, and common deadlines that affect processing.

Essential components to include on a professional form

A professional Certificate of Dependency Form combines precise identity, relationship, financial support data, supporting evidence, declaratory statements, and clear signature and notarization fields to ensure enforceability and administrative clarity.

Identity Details

Record full legal names, date of birth, and identification numbers where required. Include issuer and ID type to enable cross-checking against government records and reduce verification delays.

Relationship Facts

Describe the legal relationship, date of relationship commencement, and any custody or guardianship orders. Specify whether the dependent is a stepchild, foster child, or otherwise, with supporting court documentation as applicable.

Support Evidence

Detail the type and amount of financial support provided, dates of support, and proof such as bank transfers, shared tax returns, or signed affidavits demonstrating regular support.

Residency Information

Include current residential address, duration of residency, and documents proving physical presence such as school records, utility bills, or landlord statements covering the relevant period.

Declaration Statement

A clear declarative clause signed under penalty of perjury or statutory affirmation where required; state the truthfulness of the facts and an acknowledgement of potential penalties for false statements.

Signature Block

Provide space for printed name, signature, title or relationship, date, and notary acknowledgement or witness lines as demanded by the recipient or state statute.

Security and authentication elements to protect records

Encryption in Transit: TLS 1.2 and 1.3 encryption
Encryption at Rest: AES-256 encryption for stored data
Certifications: SOC 2 Type II, ISO 27001, PCI DSS
Authentication Options: Email, SMS code, KBA, SSO options
Audit Trail: Detailed timestamps, IP, and action logs
HIPAA & BAA: BAA available to support HIPAA compliance

Key legal and financial risks to avoid

Tax Penalties: Failure may trigger penalties under IRC §6721
Backup Withholding: 24% withholding for incorrect TIN
Benefit Denial: Ineligible dependents may lose coverage
Legal Liability: False statements risk perjury charges
Processing Delays: Missing documents cause extended reviews
Notarization Failure: Improper notarization may void form

Common pitfalls that delay approval

  • Submitting incomplete identification details, such as missing middle name or mismatched surname, commonly causes verification delays and additional documentation requests.
  • Using P.O. boxes instead of physical addresses undermines residency claims for school, tax, and benefit eligibility, prompting agency rejections.
  • Uploading illegible scans, low-resolution images, or incomplete certified copies frequently leads to requests for originals, slowing the approval process.
  • Failing to follow the receiving agency's specified format, authentication, or notarization instructions risks rejection even when substantive proof exists.

How the submission and verification workflow typically runs

Typical submission workflow for a Certificate of Dependency Form, from document preparation through verification and final acceptance.

  • Prepare Document: Use official form and complete all required fields
  • Collect Evidence: Attach certified documents and digital scans
  • Authenticate Signatures: Apply signatures, obtain notarization or RON
  • Submit & Track: Send to agency, retain audit trail and copies

Online workflow settings for digital completion

Configure an online workflow to collect, verify, and store Certificate of Dependency Forms electronically with audit logging.

Field Configuration
Document Type Fillable PDF with required attachments
Authentication Email link plus optional SMS code
Notifications Auto-email on completion to stakeholders
Storage & Retention Encrypted cloud storage, retention policy applied

Platform features to check before eSubmission

Choose a platform that supports secure e-signing, optional RON, common integrations, and HIPAA-compliance where applicable.

  • File Formats: PDF, DOCX, and scanned images
  • Integrations: Salesforce, Google Workspace, NetSuite
  • Authentication: Email, SMS, KBA, SSO options

Typical timelines and recipient-specific deadlines

Key submission and response timelines for Certificate of Dependency Forms vary by recipient; note common deadlines and processing expectations below.

Employer Benefits:

Submit within plan enrollment or qualifying event periods

Insurance Claims:

File before policy deadlines; verify insurer timelines

Tax Reporting:

Provide forms to payer upon request (W-9 timing)

Agency Review:

Allow two to six weeks for verification depending on volume

Notary Retention:

RON audio/video and journals may be retained five years

Pricing and feature comparison for popular eSignature vendors

Comparison of entry-level pricing and core features for popular eSignature vendors to consider when collecting signed Certificates of Dependency.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial, no credit card Check vendor website for trial Check vendor website for trial Check vendor website for trial Check vendor website for trial
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No envelope cap; unlimited sending on paid plans Limit of 100 envelopes per user per year Varies by plan and licensing agreement Varies by plan; consult vendor Varies by plan; consult vendor

Practical tips to reduce rework and speed approval

Practical tips to minimize rejection risk and speed processing when preparing a Certificate of Dependency Form.

Verify Identity and Names
Confirm that names and identification numbers exactly match government-issued IDs and tax records. Avoid initials or nicknames, and cross-check Social Security or TIN entries to prevent backup withholding, delays, or requests for corrected forms from payers or agencies.
Use Certified Documents
Whenever possible provide certified or original documents such as birth certificates or court orders. Scans may be accepted, but certified copies reduce later requests; ensure documents are legible, dated, and contain issuer seals or stamps when required by the recipient.
Follow Recipient Instructions
Always follow the filing instructions of the receiving organization: required attachments, notarization, witness counts, or specific forms. Deviating from prescribed formats often causes rejection even when supporting facts are correct.
Keep Copies and Audit Trail
Retain signed originals or certified copies, and preserve digital audit trails showing signer email, IP, timestamps, and notarization evidence. These records support dispute resolution and satisfy ESIGN/UETA retention requirements for electronic records.

Two practical examples that illustrate common use cases

Real-world examples show how Certificates of Dependency are used across organizations and typical verification outcomes.

School Enrollment

A school district required proof of dependent residency and guardianship for out-of-district enrollment, collecting affidavits and utility bills as evidence.

  • Scanned certified documents accepted with notarized affidavit
  • The district standardized the Certificate of Dependency Form, required notarized affidavits for disputed cases, and implemented a retention policy to keep records for five years, reducing verification time and minimizing enrollment disputes.

Employer Benefits

An employer needed dependent verification during open enrollment to confirm eligibility for family health coverage and dependent flexible spending accounts.

  • Require W-9 or TIN verification documents
  • The employer used standardized forms, requested SSN matching for tax reporting, and accepted certified scans for most cases; cases with discrepancies required notarized affidavits before benefits were activated to prevent improper coverage.

Primary signers and verifiers

Sponsor / Parent

A sponsor or parent completes the form to assert dependent status, providing identification, proof of relationship, and financial documentation. They must sign under penalty of perjury if required and may need notarization depending on recipient rules.

Institutional Verifier

An employer, insurer, or agency official reviews submitted documents, verifies identity and supporting evidence, and records acceptance or denial. Their countersignature or intake stamp often finalizes acceptance for administrative or benefit purposes.

Recommended export formats and archival practices

Export signed certificates and attachments in standard formats for recordkeeping and submission; choose formats that preserve signatures and comply with recipient requirements.

PDF/A

Use PDF/A for archival copies of signed certificates and attachments; it preserves layout, fonts, and embedded signatures, ensuring long-term readability and admissible audit evidence.

DOCX

Keep an editable DOCX copy for internal recordkeeping and future amendments; avoid submitting DOCX to recipients who require locked or notarized PDFs to prevent tampering concerns.

Scanned Images

Scan originals at 300 DPI or higher, save as PDF, and ensure images are legible. Include a cover page listing attached items to simplify reviewer navigation.

Certificate of Completion

Retain a signed certificate of completion or audit report that records signer identity, timestamps, and authentication method; include this with digital archive copies to support legal admissibility.

Milestones from preparation to final acceptance

Sequential milestones from initiation through verification to final acceptance when processing a Certificate of Dependency Form.

01

Preparation and Documentation

Gather IDs, evidence, and complete the form fully.

02

Submission and Authentication

Submit form to recipient and authenticate signatures.

03

Verification and Review

Recipient reviews documents, may request originals or notarization.

04

Acceptance and Recordkeeping

Form accepted, archive copies and retention applied.

How the Certificate compares with similar documents

Key distinctions between a Certificate of Dependency and an Affidavit of Support to help determine which document suits your administrative or legal need.

Criteria Certificate of Dependency Affidavit of Support
Purpose eligibility verification financial sponsorship
Typical Signer sponsor/guardian sponsor (financial supporter)
Notarization varies by recipient often required
Financial Proof support evidence required bank statements, affidavit
Common Use benefits, enrollment immigration, visa support

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