Fill and Sign the Domestic Partnership Certification Form

DOMESTIC PARTNERSHIP DEPENDENT CERTIFICATION FORM This form is used by a { Insert Name of Company } employee to determine his/her imputed tax liability status for domestic partnership benefits. Please check the appropriate statement and complete the employee portion of the form, then forward the form to your benefits representative. This is to certify, under the penalty of perjury, that effective with tax year       , I, __________________________________ , am claiming my domestic partner, __________________________________ , as my dependent for purposes of federal income tax. I understand that should I no longer declare my domestic partner as a dependent for tax purposes, that I will immediately notify the benefits/payroll department. In addition, if I fail to make to make this notification, I may be held liable for any and all taxes due based on when the dependency ended. By signing this document, I agree, upon request, to provide the company access to my tax records, domestic partner filing documents, and/or any other supporting documentation as needed to verify dependency for federal income tax purposes. This is to certify, under penalty of perjury, that effective with tax year       , I, __________________________________ , am no longer claiming my domestic partner as a dependent for the purposes of my federal income taxes. I understand that by rescinding this certification, the domestic partnership benefits will be taxes as imputed income for federal income tax purposes. ______________________________ ____________________________ Employee Signature Employee Social Security Number Date Signed: ___________ _____________________________ Date Signed: ___________ Benefits Representative’s Signature cc: Employee Human Resources/Payroll