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Statement of Domestic Partnership

Employee Name: First Last Employee SSN: Social Security Number Partner Name: Partners Name, Partner SSN: Partner Social Security Number, Department: Department Supervisor: Supervisor. Please complete the following form, signing both employee and partner's names on each line, and return it to the Human Resources Department.

We affirm or attest that we are:

At least 18 years of age:

Mentally competent and legally able to enter into a contract at the time this domestic partnership statement is completed:

The sole domestic partner to one another:

Sharing and co-habiting in a primary residence:

Not married to any other person (legal or otherwise) or of a blood relationship that would prohibit marriage in the State of State:

In a relationship of mutual caring, support, and commitment, and intend to remain in such a relationship for the foreseeable future:

Domestic Partnership Verification

Upon request, we understand that we may be asked to produce the following documents:

One of the following

A Domestic Partnership Certificate. A Domestic Partnership Registration. A Domestic Partnership Contract or Agreement entered into by both employee and partner. A Certificate of Marriage.

Any legal document issued by any governmental body that can be considered the unilateral equivalent to a marriage certificate or agreement.

Or any two of the following:

A revocable living will, trust, or other living trust agreement that names one another. A durable power of attorney or living will (naming each other). Proof of joint tenancy or documents that verify that the employee and partner have lived together previously for a period of at least Months months. Proof of joint legal guardianship of a child or children.

Joint utility bills or proof of other monthly expense(s). A printed invitation, announcement, or other proof of a "Commitment Ceremony" or other Ceremony in which commitment is affirmed to one another. Proof of life insurance documents or policies in which each partner is named as a beneficiary.

Joint bank or other financial account documentation. A recorded will bequeathing assets or personal belongings to one another. Proof of joint ownership of an automobile or vehicle.

Proof of joint ownership of another piece of tangible property or asset. Rights, Responsibilities, and Understanding Concerning This Statement of Domestic Partnership.

We, the undersigned, understand that the employee named below shall be obligated to file a Notice of Termination of Eligibility, available from the Human Resources Department, with the Company health plan administrator within 30 days of:

The date on which we no longer meet the above criteria for domestic partnership;. The date on which we become legally married;. The death of a Domestic Partner.

We further understand that stating our Domestic Partnership and the acknowledgement of such by the Company may subject one or both of us to binding legal obligations to one another; including, but not limited to obligations to the Internal Revenue Service (IRS), State Tax obligations, or other taxing authorities and obligations. We understand that Company Name is not offering legal advice or recommendations concerning such, and that we should consult an attorney to learn the extent of those obligations. We understand that the Company will keep this Statement of Domestic Partnership and all other enrollment forms private and confidential. These documents are to be used by the Company Human Resources Department in order to procure, provide, and otherwise administer benefits to its employees and their beneficiaries and to be further filed or used as required by law.

We hereby swear and affirm that the information provided in this agreement is true and accurate to the best of our knowledge, information, and belief. We understand that we shall be held liable for the information contained in this agreement and any benefits granted by the Company, its insurers, and all governing bodies due to obtaining Domestic Partner status. We represent that this Statement of Domestic Partnership was not obtained by coercion, duress, or by fraudulent means. We agree to notify the Company Human Resources Department, in writing, of any changes to the status of this Domestic Partnership relationship or of any relevant information that may affect the eligibility to any benefits offered while employed at Company Name.

Employee Signature Date

Partner Signature Date

Human Resources Representative Date