Writing the Domestic Partnership Termination Form document
Termination of Domestic Partnership Current Date. Please complete the following form, signing both employee and partner's names on each line, and return it to the Human Resources Department. NOTE: This Termination of Domestic Partnership Statement may affect any current coverage for your Domestic Partner and/or the rates you pay under any Company Insurance Plans or Company-sponsored benefits. I hereby declare that my former Partner, (please print), and I are no longer Domestic Partners and our Domestic Partnership ended on this date.
Employee Signature Date
Partner Signature Date
Human Resources Representative Date
Phone Phone Number