Domestic partnerships between opposite-sex partners will not be affected. AFFIDAVIT OF DOMESTIC PARTNERSHIP I. I and are Domestic Partners. Upon termination of this Affidavit of Domestic Partnership (evidenced by a Statement of Termination of Domestic Section C. Representations and Understandings 1) I provide the information in this Affidavit to be used by the University for the sole purpose of I, _____, submit this Affidavit of Domestic (Name of Retiree) Partnership to establish _____ as my Domestic (Name of Domestic Partner) Partner (as defined below) for the purpose of obtaining benefits that the City of Tacoma may extend to retirees' Domestic Partners. Affidavit of Domestic Partnership Declaration of Establishment or Termination 1800 Grant Street, Suite 400 t 303-860-4200 Denver, CO 80203 f 303-860-4299 employeeservices@cu.edu 1-855-216-7740 1 of 3 Employee Services Benefits and Wellness | affidavit of domestic partnership Revised: February 15, 2022 | benefits@cu.edu We submit original documents of two of the following items (at least one of the two must be from List A.) THE PARTNERS On _____, 20____, this Affidavit ("Affidavit") declares the following individuals to be considered in a Domestic Partnership: Partner 1: _____, and Partner 2: _____. A joint ownership or a lease for a residence identifying both partners as tenants; or v. A will and/or life insurance policies which designate the other as primary beneficiary. A domestic partner affidavit is a declaration made by a couple that both acknowledge being engaged in a domestic partnership (under state law). This gives each partner special rights (such as hospital visitation, inheritance, etc.) DECLARATION OF DOMESTIC PARTNERSHIP Partner 1 and Partner 2 shall be referred to as the "Couple" and declare to be domestic I, , state the following based upon my own personal knowledge: and I are no longer domestic partners. domestic partner (and domestic partner's child/children) coverage ends the last day of the month in which they no longer meet the eligibility requirements. We will notify the Plan within thirty (30) days of such change by filing a Statement of Termination of Domestic Partnership with the Plan. You can title the affidavit as "Affidavit of Domestic Partnership" or "Domestic Partnership Affidavit." It should capture the attention of the readers and tell what the affidavit is all about. Specifically, I declare and acknowledge that I and my Domestic Partner named above meet the following criteria: - Are both at least 18 years old The affiant is the person who will sign the affidavit. Are responsible for each other's welfare and are each other's sole domestic partner; 3. 6. 87505 MAILING ADDRESS: PO BOX 6850, SANTA FE, NEW MEXICO 87502-6850 D ABINET AY R AFFIDAVIT OF DOMESTIC PARTNERSHIP As required by Executive Order 2003-010, this affidavit must be used to apply for domestic partner benefits and must be filed with the state employee's human resources office. Change in domestic partnership: We agree to notify the Plan if there is any change in our status as domestic partners as attested to in this Affidavit which would make us no longer eligible for benefits. I make and file this Statement of Termination in order to cancel the Affidavit of Domestic Partnership, dated . Neither of us has terminated another registered domestic partnership within the last 30 calendar days. 2. Notary Acknowledgment - It is commonly required for this form to be notarized. EXCEPTION: If at least one partner is age 62 or older, the couple may remain domestic partners. affidavit of domestic partnership texasne or iPad, easily create electronic signatures for signing a affidavit of domestic partnership in PDF format. Notary Public My Commission Expires Please provide the original to BCBS along with your application. a "domestic partnership" is one consisting of two persons in which the following applies: 1. Affidavit of Domestic Partnership Cigna HealthCare Affidavit of Domestic Partnership The undersigned, being duly sworn, depose and declare as follows: We are each eighteen years of age or older and mentally competent. 5. signNow has paid close attention to iOS users and developed an application just for them. WE CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT Notary Public My Commission Expires 45331.1017 Domestic Partner's name (please print) Employee's name (please print) Each of us agrees to file jointly or separately an Affidavit of Termination in the event that the domestic partnership is terminated. If either or both of us has been married, we submit evidence of the termination of the marriage. Domestic Partner's name (please print) Employee's name (please print) . To find it, go to the App Store and type signNow in the search field. I affirm that we are Domestic Partners and meet the Domestic Partnership eligibility requirements and reside together at: (street address) DOCUMENTATION OF DOMESTIC PARTNERSHIP I am an employee of Case Western Reserve University (Case), have attached to this affidavit the following as documentation of the domestic partnership: (Please check the items submitted): An Acknowledgement of Domestic Partnership Agreement, which acknowledges that an agreement exists between myself and my domestic partner AFFIDAVIT OF DOMESTIC PARTNERSHIP STATE OF ) :SS. iv. Are not married to anyone and either has not had a spouse or another domestic partner within the prior six months Change in Domestic Partnership 1. "Domestic Partners" means two adults who have chosen to share their lives (Domestic Partner) in an intimate and committed relationship, reside together, and share a mutual obligation of support for the basic necessities of life. I and _____ are domestic partners and we meet all of the ( Name of Domestic Partner) following criteria: filed until one (1) year after a Statement of Termination of Domestic Partner Status of the most recent domestic partnership has been filed with the Office of Human Resources. Termination of Domestic Partnership A. Both are at least 18 years of age; 2. We have resided together in the same legal residence for at least 12 consecutive months as each other's sole domestic partner. We agree to all of the terms of this affidavit and declare the following: A.e are adults and neither of us is legally married or the partner in a lawful W civil union. A false declaration of a domestic partnership will result in a retroactive termination of benefits of the domestic partner and domestic partner's eligible child/children in the Plan. 7. the Certificateholder has completed and submitted this notarized Affidavit Of Domestic Partnership to the Contractholder and the Contractholder has approved this Affidavit of Domestic Partnership. Identify the Affiant Right after the title, indicate the affiant's identity in the body. II. The affidavit must be notarized. without being legally married. 12) We provide the information in this affidavit to be used by the University for the sole purpose of determining our eligibility for domestic partnership benefits. Retain a copy for your records. domestic partner. described as 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. : COUNTY OF ) The undersigned, being duly sworn, depose and declare as follows: We are both eighteen (18) years of age or older and are mentally competent to consent to contract. 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. Affidavit of Financial Interdependence The undersigned, being duly sworn, depose and declare as follows: We are domestic partners who reside together and are financially interdependent. "AFFIDAVIT OF DOMESTIC PARTNERSHIP" and who executed same as a free and voluntary act for the uses and purposes stated herein. We are not related by blood in a manner that would bar marriage under the laws in the State we reside. 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); or if we wish to terminate domestic partner benefits. as proof of our financial interdependence: The above date is within 30 days of the termination of our domestic partnership. Both the Covered Person and the Domestic Partner must jointly sign the required Affidavit of Domestic Partnership. Section 1 - This affidavit applies to the following University-sponsored benefit plans (please check all that apply): Group Term Life Insurance (MetLife) Dental Insurance (MetLife) This affidavit is to be completed by both the employee and the declared domestic partner. Statement of Termination of Domestic Partnership 1. 3. II.

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