Hawaii Declaration of Termination of Reciprocal Beneficiary Relationship
Official state formOther requestsFree downloadLast verified November 10, 2026
Notarized declaration to end a registered reciprocal beneficiary relationship under HRS chapter 572C. It is mailed to the RBR Office of the Hawaii Department of Health. Mail only.
Who can use this form
- Either party to the reciprocal beneficiary relationship can use this form.
- The signature of at least one registrant is required.
- The signature is made before a notary.
What to send with it
- The notarized declaration.
- $8.00 money order or certified check payable to State Director of Finance (the office's page says cashier's check).
- One stamped, self-addressed, legal-size envelope for each certificate address.
Where to send it
- Mail to
- State Department of Health Office of Health Status Monitoring ATTN: RBR OFFICE PO Box 3378 Honolulu, HI 96801
- State fee
- $8.00. Extra copies of the certificate of termination cost $8.00 each.
- Typical processing
- Not provided
- Form revision
- REV 2021 B
- Source
- Official government page