Fill and Sign the Domestic Partners Benefits Form

Affidavit of Both Domestic Partners to Employer in Order to Receive Benefits STATE OF ____________________ COUNTY OF _______________________ PERSONALLY appeared before me, the undersigned authority in and for said county and state, ______________________________________________ (Names of Affiants) , who, having been being first duty sworn by the undersigned Notary Public, depose and say: The undersigned Affiants are domestic partners in accordance with the following criteria and eligible for benefits coverage under the ____________________ (Name of Employer) ’s benefit programs: A. We are each other’s sole domestic partner and intend to remain so indefinitely. B. We are jointly responsible for each other’s common welfare, share financial obligations and share our primary residence. We have resided together for at least six (6) continuous months prior to the date of this affidavit. We will, along with this Affidavit, provide evidence of joint responsibility , and agree that joint responsibility must be demonstrated by the existence of either: 1. A civil union licensed under _________________ (name of state) law. We agree that a civil union is defined as a legally recognized union between same sex partners; or 2. Two or more of the following, and we have checked the items that apply to us and that we are hereby supplying to _______________________ (Name of Employer) : [ ] Copy of Domestic Partnership Agreement . [ ] Copy of j oint mortgage or joint ownership of primary residence. [ ] Two of the following: ______1. Joint ownership of motor vehicle (i.e., copy of certificate of title). ______2. Joint checking account (i.e., copy of depositors’ agreement). ______3. Joint credit account (i.e., copy of depositors’ agreement). ______4. Copy of joint lease. [ ] Satisfactory evidence that t he domestic partner has been designated as a beneficiary for employee’s will, retirement contract, or life insurance. 3. We are not married to anyone, each at least eighteen (18) years of age, mentally competent to consent to a contract, and not related by blood to a degree of closeness which would prohibit marriage in the State of _______________________ (Name) . 4. We understand and agree that domestic partners are subject to the other eligibility provisions of _______________________ (Name of Employer) ’s benefit plans. 5. We understand and agree that falsification of information contained in this Affidavit may lead to disciplinary action, up to and including immediate termination of employment, and may subject us to civil action to recover any losses, including reasonable attorney’s fees, in addition to an obligation to repay benefits received. ___________________________________ (Printed Name of Affiant) ___________________________________ (Signature of Affiant) ___________________________________ (Printed Name of Affiant) ___________________________________ (Signature of Affiant) SWORN to and subscribed before me, this the ____ day of _____________, 20____. _____________________________ NOTARY PUBLIC My Commission Expires: ___________________