Affidavit of Domestic Partnership

Affidavit of Domestic Partnership for Employer in Order to Receive Benefits

Full Name of Employee

Social Security Number

Full Name of Domestic Partner

Social Security Number of Partner

Note: For purposes of this Affidavit, “Domestic Partners” are defined as two individuals of the same sex or of different sexes:

• who are both 18 years of age or older and have the capacity to enter into a contract; and

• who are involved in an exclusive, long-term and committed relationship; and

• who have resided together in a common household continuously for at least six (6) consecutive months; and

• who intend to reside together indefinitely; and

• who are not related by blood to a degree of closeness which would prohibit legal marriage in the State in which the partners legally reside; and

• who have agreed to be jointly responsible for each other’s welfare, financial obligations, and basic living expenses, including food, shelter, and health care expenses; and

• who are not married, who are not currently involved in any other domestic partnership, and who have not been involved in any other domestic partnership or marriage for the last twelve (12) months, unless that partnership or marriage ended because of death.

STATE OF

COUNTY OF

PERSONALLY appeared before me, the undersigned authority in and for said county and state, (Name of Affiant), who, having been being first duty sworn by the undersigned Notary Public, deposes and says:

1. I am an employee of (Name of Employer), and I have attached to this Affidavit the following as documentation of the Domestic Partnership:

(Items submitted are checked):

An Acknowledgement of Domestic Partnership Agreement, which acknowledges that an agreement exists between myself and my domestic partner that creates personal and financial liability and responsibility for each other’s welfare, financial obligations, and basic living expenses, including food, shelter, and health care expenses.

Copy of joint deed, joint mortgage agreement, or joint lease.

Copy of designation of the domestic partner as primary beneficiary for a life insurance contract or retirement account.

Designation of domestic partner as primary beneficiary of will (i.e., copy of will).

Copy of durable power of attorney for health care or financial management designating domestic partner as attorney-in-fact.

Joint ownership of a motor vehicle (i.e., copy of certificate of title)

Joint checking account (i.e., copy of depositors’ agreement)

Joint credit account (i.e., copy of depositors’ agreement)

Copy of co-parenting or adoption agreement

2. I understand and agree to all of the following:

A. Domestic partners are eligible for all benefits of (Name of Employer) when the insurance carriers or the benefit provider permits benefits to be extended to domestic partners;

B. Coverage for non-employee domestic partners may only be activated during open enrollment and is effective for one calendar year. Coverage may begin during the calendar year only if a qualifying change in family or job status occurs during that calendar year.

C. Domestic partners are not eligible for continuing coverage under COBRA;

D. The employee must give written notice to Human Resources within thirty (30) days of any change of circumstances attested to in this Affidavit or of the termination of the domestic partnership, and file an amendment to the Affidavit or a termination of the Affidavit form;

E. Another Affidavit of Domestic Partnership cannot be filed until twelve (12) months after a statement or termination of the previous partnership has been filed with Human Resources of (Name of Employer), unless that domestic partnership ended because of death;

F. Falsely certifying eligibility for domestic partner benefits or failing to inform (Name of Employer) if the domestic partnership ceases to meet eligibility requirements in any respect will result in disciplinary action against the employee;

G. Employee will be liable for all expenditures for coverage and benefits that the employee obtained because of any misrepresentation or omission on this Affidavit, in certifying eligibility for benefits, or in failing to inform (Name of Employer) that the domestic partnership ceases to meet eligibility requirements; and

H. Employees of (Name of Employer) are permitted to use the information provided on this Affidavit to administer the benefits outlined above.

SWORN to and subscribed before me, this the day of , 20 .