We understand that the information contained in this affidavit will be held confidential and will be subject. The 12month period will be waived only if another domestic partner affidavit, approved by anthem and by the group, is filed for the same domestic. The partners enrollment will take effect only if you submit this affidavit to your agencyuniversity benefits. Domestic partnership affidavit domestic partners square suffix lot and print name of partner 1 print name of partner 2 each being duly sworn, on their oaths do severally depose and state that they are presently domestic partners, as certified by the department of health, district of columbia. The definition of domestic partner for purposes of this affidavit shall be two individuals, irrespective of gender, who live. We certify that is a domestic partner of in accordance with the following eligibility criteria.
Affidavit of qualifying domestic partnership section i statement of domestic partnership employees name domestic partners name street address city state zip code id. After submitting the forms, the employee may not file a new affidavit of domestic partnership for the purpose of. To terminate your domestic partnership and enrollment of your domestic partner in these benefits, you need to file a kaiser permanente termination of domestic partnership or provide a copy of the notice of termination of domestic. All documents except a license or certificate for a civil union, marriage license or affidavit registration of domestic partnership from a jurisdiction, which recognizes civil unions, domestic partnerships andor samesex marriages must be valid for the past twelve 12 months. Affidavit of domestic partnership for benefits eligibility when you add domestic partner coverage to your benefit program, the employee and his or her domestic partner must meet certain eligibility criteria. Use this templateform as an affidavit of domestic partnership form in the state of maryland marylandaffidavitofdomesticpartnership text version of.
We share a close personal relationship and are each others sole domestic partner. We agree to notify the city of albuquerque human resources department. After termination of this affidavit, i understand that another affidavit of domestic partnership for health insurance benefits cannot be filed until the end of a six 6 month period following final. Affadavit of domestic partnership small business majority.
If you cover a domestic partner of the same sex and legally married, you can add your domestic partner and your deductions. If the partners do not live within new york city, then at least one partner must be an employee of the city of new york in order to register a domestic partnership from the office of the city clerk. A signed city affidavit of domestic partnership form and appropriate identification. Evidence and certification of domestic partnership. Additionally, we acknowledge that filing this affidavit does not automatically result in the naming of the nonemployee domestic partner as a beneficiary for the employee domestic partners life insurance, 403b plan or any. Affidavit of domestic partnership ardent offers its employees the ability to provide benefits for their same or oppositesex domestic partner who meets the eligibility requirements listed. This form is only required for domestic partnerships not documented in a state registry. I agree to notify h uman resources if there is any change in our status as domestic partners as certified and acknowledged in this statement. Domestic partners registry california secretary of state. No individual who has filed an affidavit of domestic partnership may file another such affidavit to qualify for domestic partner benefits until at least twelve 12 months have elapsed following the date a statement of termination has been filed with the benefits administrator ending a previous partnership status. Affidavit of domestic partnership each of the undersigned attests that heshe satisfies the definition of domestic partnership set forth in the applicable certificate of coverage and. Contact your executive benefits specialist 3190 cal 05032012 4 page 1 of 3. We agree to notify the utah state university office of human resources in writing within thirty 30 calendar days of any change in our status as domestic partners for example, if we no longer share the same principal residence. I affirm and declare that the information in this affidavit is true and complete to the best of my knowledge.
Review and complete this affidavit to declare the establishment or termination of a domestic partnership for purposes of dependent. Affidavit of samesex domestic partnership cannot be filed until six months after the date of the filing of the statement of termination. To obtain domestic partner benefits under the city domestic partnership affidavit, you and your domestic partner must meet the following conditions and attest to this by completing and signing an affidavit of domestic partnership. The domestic partners registry registers samesex couples regardless of the age of the partners, and oppositesex couples in which one partner is at least 62 years old, as domestic partners in. We provide the information in this affidavit to be used by my human resources associatefor the sole purpose of determining our eligibility for domestic partnership benefits. Upon termination of this affidavit of domestic partnership evidenced by a statement of termination of domestic partnership. Domestic partnership is defined in the certificate of coverage. The termination of this domestic partnership is irrevocable once the department of employee trust funds receives this completed affidavit. We are not married to anyone else and do not have another domestic partner.
Affidavit of domestic partnership for benefits eligibility. After submitting the forms, the employee may not file a new affidavit of domestic partnership for the purpose of enrolling a new partner for six months from the date the termination of domestic partnership form is received by the employer. A registered state of california declaration of domestic partnership form, or proof of a similar. I understand that it is possible that this statement may create certain legal and tax. As of the date that this domestic partnership terminates, a domestic partner ceases to be eligible for the benefits that are available to domestic partners under chapter 40. We are at least eighteen 18 years of age and are mentally competent to.
Affidavit of domestic partnership for benefits eligibility blue cross. Affidavit of domestic partnership ardent offers its employees the ability to provide benefits for their same or oppositesex domestic partner who meets the eligibility requirements listed below, assuming adequate documentation is submitted. A domestic partnership shall be deemed to exist between two persons of the same or opposite sex if both complete and. Both partners agree that a subsequent domestic partner affidavit cannot be filed until 12 months after any statement of termination is received by the group. Use this templateform as an affidavit of domestic partnership form in the state of maryland maryland affidavit of domestic partnership text version of. Each of the undersigned attests that heshe satisfies the definition of domestic partnership set forth in the applicable. Are not related by blood, not legally married, nor in a domestic partnership with anyone. Domestic partnership is defined in the certificate of. If the domestic partner relationship is terminated, coverage.
Statement of termination shall affirm that the domestic partnership status is terminated as of the date of execution specified therein and that a copy has been mailed to the other party by the. When you add domestic partner coverage to your benefit program, the employee and his or her domestic partner must meet certain eligibility criteria. If the partnership ends or the partner becomes e nrolled in another employer. A nditio ember o dmes partner e ligib hildren ollowin a us mplet. Affidavit of domestic partnership for benefits eligibility when you add domestic partner coverage to your benefit program, the employee and his or her domestic partner must meet certain. We have lived together for at least six months prior to enrollment in the plan. As an example and reminder, a legally recognized marriage to your domestic partner would constitute a change of circumstance that should be communicated. Affidavit of domestic partnership sample i declare, under penalty of perjury under the laws of the state of california, that the statements below are true and correct. I understand that i cannot file another affidavit of domestic partnership with. Haverford college affidavit of domestic partnership. Each of the undersigned attests that heshe satisfies the definition of domestic partnership set forth in the applicable certificate of coverage and the provisions in section i, below, and agrees to the requirements set forth in section ii, below. Affidavit of domestic partnership new york university the university provides benefits to your domestic partner and his or her children, provided that you and your domestic partner sign and complete this affidavit of domestic partnership in the presence of a notary public or a representative of nyu peoplelink, the universitys hr. I further understand that this affidavit of termination of domestic partnership initiates no change to my actual insurance coverage.
We are both at least 18 years of age, and are under no legal disability which would prevent them from making this affidavit. I understand that another affidavit of domestic partnership cannot be filed until six 6 months after the most recent domestic partnership has been terminated. The domestic partners registry registers samesex couples regardless of the age of the partners, and oppositesex couples in which one partner is at least 62 years old, as domestic partners in california when they file a declaration of domestic partnership. The partners enrollment will take effect only if you submit this affidavit to your agencyuniversity benefits office during open enrollment or within seven days following the close of open enrollment or the domestic partner will not receive coverage. All documents except a license or certificate for a civil union, marriage license or affidavitregistration of domestic partnership from a jurisdiction, which recognizes civil unions.
In writing within thirtyone 31 days of any change in our status as domestic. I understand that i cannot file another affidavit of domestic partnership with you until twelve 12 months after the statement of termination of the previous partnership has been filed. After termination of this affidavit, i understand that another affidavit of domestic partnership for health insurance benefits cannot be filed until the end of a six 6 month period following final termination of domestic partnership. Affidavit of domestic partnership get ardent benefits. Can demonstrate financial interdependence as required below, and. Statement of termination shall affirm that the domestic partnership status is terminated as of the date of execution specified therein and that a copy has been mailed to the other party by the party authorizing the action. Learn about proper identification required for a domestic partnership registration. Review and complete this affidavit to declare the establishment or termination of a domestic partnership for purposes of dependent eligibility for a domestic partner. We agree to notify the utah state university office of human resources in writing within thirty 30 calendar days of any change in our status as. If the domestic partner relationship is terminated, coverage for the domestic partner will terminate at the end of. If you cover a domestic partner of the same sex and legally married, you can add your domestic partner and your deductions will be taken on a pretax basis.
Affidavit of qualifying domestic partnership section i statement of domestic partnership employees name domestic partners name street address city state zip code id number group number date domestic partnership began we are 18 years of age or older. I affirm, under penalty of perjury, that the foregoing is true and. Affidavit of domestic partnership new york university the university provides benefits to your domestic partner and his or her children, provided that you and your domestic partner sign and. If the partners do not live within new york city, then at least one partner. I also understand that an affidavit of termination of domestic partner status must. Affidavit of domestic partnership each of the undersigned attests that heshe satisfies the definition of domestic partnership set forth in the applicable certificate of coverage and the provisions in section i, below, and agrees to the requirements set forth in section ii, below. I agree to provide a copy of the statement of termination to my former domestic partner.
Domestic partner in the above document entitled affidavit of domestic partnership and who executed same as a free and voluntary act for the uses and purposes stated herein. You may enroll your domestic partner through the online system. Affidavit of domestic partnership laramie, wyoming. No individual who has filed an affidavit of domestic partnership may file another such affidavit to qualify for domestic partner benefits until at least twelve 12 months have elapsed. We understand that this affidavit of domestic partnership will cease to be valid on the earlier of december 31, 2020. Affidavit of domestic partnership pinellas county, florida. An affidavit is a means by which you may confirm that these eligibility requirements are met. Once we provide notice of a change in domestic partner status, we understand that another affidavit of samesex domestic partnership cannot be filed until six months after the date of the filing of the statement of termination. To terminate your domestic partnership and enrollment of your domestic partner in these benefits, you need to file a kaiser permanente termination of. Change in domestic partnership we agree to notify the city of albuquerque human resources department in writing within thirtyone 31 days of any change in our status as domestic.
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