Domestic Partnership Declaration Form

Miami Dade College
Declaration of Domestic Partnership Certification

We, and certify to Miami Dade College that we are Domestic Partners in accordance with the following criteria.

A. CRITERIA

1. We are each other’s sole Domestic Partner with the intention to remain so indefinitely. We are in an affectionate relationship of mutual support, caring and commitment. We share joint responsibility for the household.

2. Neither one of us is legally married to someone else. We are not related by blood.

3. We each are at least eighteen (18) years of age.

4. We have resided together for at least 12 months and intend to reside together indefinitely.

5. We have shared financial responsibilities.

6. We are mentally competent to consent to a contract.

B. REQUIRED PROOFS

At least four of the following:

Joint ownership of real estate property

Designation as beneficiary in each other’s will

Designation as attorney in a durable power of attorney document

Joint ownership of significant assets

Designation as health care surrogate

Joint loan

Joint credit card

Joint lease

C. ACKNOWLEDGMENTS

By signing this Declaration, I acknowledge that I have been informed that:

1. I may add my domestic partner during the open enrollment period after meeting the requirements noted in A and B above OR by submitting this form no later than 30 days after meeting the requirements.

2. The employee benefits available to the Domestic Partner of a College employee are Health, Dental, Life Insurance, Group Legal, and Long Term Care Plans. Domestic Partners are subject to the same policies and guidelines, which govern these benefits generally. The plan documents, College policy and the insurance contracts govern all questions of coverage.

3. Miami Dade College reserves the right to request proof that my partnership meets the joint residency and financial interdependency eligibility criteria and I agree to provide supporting documents when requested to do so.

4. The Internal Revenue Service currently treats as imputed income the value of the medical and/or dental coverage provided to my domestic partner and his/her dependent(s), if any, minus any contribution paid by me for this coverage. I understand that I will be responsible for federal income tax, if any, on the value of the income imputed to me for these benefits.

5. By enrolling my Domestic Partner with Miami Dade College, my Domestic Partner and his/her dependent child(ren) may be considered my “spouse” and “child(ren)” for purposes of the Family and Medical Leave Act of 1993.

6. If there is any change in our status as Domestic Partners as certified in this Statement, we will notify Miami Dade College within thirty-one (31) days of the effective date of such change. If this change results in a termination of the Domestic Partnership status, a Declaration of Termination of Domestic Partnership must be completed within such thirty-one (31) day period. The Domestic Partnership status will be terminated as of the date the signed Declaration of Termination is received in the Benefits Department of Miami Dade College.

7. At least twelve (12) months must elapse from the date the Declaration of Termination of Domestic Partnership was filed with the Benefits Department before benefits for another domestic partnership may be approved by Miami Dade College.

8. The information provided in this Declaration is for use by the Benefits Department for the purpose of determining and maintaining eligibility for Domestic Partner benefits.

9. An employee who makes false statements about satisfying the eligibility criteria or fails to notify Miami Dade College of a change in status will be subject to disciplinary action up to and including discharge and/or loss of benefits.

10. Miami Dade College may change its rules, policies and practices on Domestic Partners at any time without notice.

D. DEPENDENT CHILD CERTIFICATION

Partner’s Dependent Children

I hereby certify that the above-named child(ren) of my Domestic Partner meet all of the eligibility requirements, and I understand that falsely certifying as to a dependent’s eligibility or failure to inform Miami Dade College when a dependent no longer meets applicable eligibility requirements could result in disciplinary action, including termination of employment.

TO BE COMPLETED BY EMPLOYEE & PARTNER

I affirm that the statements made above are true and complete to the best of my knowledge. I also understand that filing this Declaration may impose upon me obligations to my Domestic Partner or to the creditors of my Domestic Partner.