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IT, web, Internet, software, hardware, media, multimedia, photography, tech, information, technology, computer, business, company, pre-written, legal, contract, agreement, documents, templates, boilerplate, form, outline, text, terms, recitals hr Company Statement Domestic Partnership CurrentDate Employee Name ContractFirstName ContractLastName Employee SSN SSN Partner Name Insert Partners First Name Insert Partners Last Name Partner SSN Partner Social Security Number Department Department Supervisor Supervisor Instructions Please complete the following form signing both employee and partner names each line and return the Human Resources Department affirm attest that are least years age Mentally competent and legally able enter into contract the time this domestic partnership statement completed The sole domestic partner one another Sharing and habiting primary residence Not married any other person legal otherwise blood relationship that would prohibit marriage the State State relationship mutual caring support and commitment and intend remain such relationship for the foreseeable future Domestic Partnership Verification Upon request understand that may asked produce the following documents One the following Domestic Partnership Certificate Domestic Partnership Registration Domestic Partnership Contract Agreement entered into both employee and partner Certificate Marriage Any legal document issued any governmental body that can considered the unilateral equivalent marriage certificate agreement any two the following revocable living will trust other living trust agreement that names one another durable power attorney living will naming each other Proof joint tenancy documents that verify that the employee and partner have lived together previously for period least Months months Proof joint legal guardianship child children Joint utility bills proof other monthly expense printed invitation announcement other proof Commitment Ceremony other Ceremony which commitment affirmed one another Proof life insurance documents policies which each partner named beneficiary Joint bank other financial account documentation recorded will bequeathing assets personal belongings one another Proof joint ownership automobile vehicle Proof joint ownership another piece tangible property asset Rights Responsibilities and Understanding Concerning This Statement Domestic Partnership the undersigned understand that the employee named below shall obligated file Notice Termination Eligibility available from the Human Resources Department with the Company health plan administrator within days the date which longer meet the above criteria for domestic partnership the date which become legally married the death Domestic Partner further understand that stating our Domestic Partnership and the acknowledgement such the Company may subject one both binding legal obligations one another including but not limited obligations the Internal Revenue Service IRS State Tax obligations other taxing authorities and obligations understand that Company not offering legal advice recommendations concerning such and that should consult attorney learn the extent those obligations understand that the Company will keep this Statement Domestic Partnership and all other enrollment forms private and confidential These documents are used the Company Human Resources Department order procure provide and otherwise administer benefits its employees and their beneficiaries and further filed used required law hereby swear and affirm that the information provided this agreement true and accurate the best our knowledge information and belief understand that shall held liable for the information contained this agreement and any benefits granted the Company its insurers and all governing bodies due obtaining Domestic Partner status represent that this Statement Domestic Partnership was not obtained coercion duress fraudulent means agree notify the Company Human Resources Department writing any changes the status this Domestic Partnership relationship any relevant information that may affect the eligibility any benefits offered while employed Company Employee Signature Date Partner Signature Date Human Resources Representative Date Address1 Address2 City State PostalCode Phone WorkPhone
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