Affidavit Of Domestic Partnership Form

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Affidavit of
- Office Use Only -
Approved by ____ Date_____
Domestic Partnership
Effective Date_______________
To add a domestic partner by affidavit to your coverage, you must submit this affidavit to your educational entity
within five business days of the electronic enrollment date or the date your enrollment form was received by your
Educational Entity. If this affidavit is not received by your educational entity within this timeframe, coverage for
your domestic partner’s will not be effective.
To add a domestic partner by affidavit, you cannot be married or have had a spouse or another domestic partner
within the last six months. If you were married, the six-month period starts on the final date of divorce.
Do not submit this form if you have a Domestic Partnership through a Registered Certificate.
Submit this completed affidavit to your educational entity.
1. I am submitting my Affidavit of Domestic Partnership
During the Open Enrollment Period
Outside the Open Enrollment Period
You must have jointly shared the same permanent
You must have jointly shared the same permanent
residence for at least six months immediately preceding
residence for six months immediately preceding the
the date of this affidavit and intend to continue to do so
date of this affidavit and enrolled in coverage
indefinitely.
within 31 days of the six month anniversary date.
Please indicate how long you have lived
Please indicate the date you began living
together:_______________
together:________________
2. Employee Information
Educational Entity
Employee ID, SSN, or E Number
Last Name
First Name
MI
Date of Birth
Gender
M
F
Contact Address
Apt #
City
State
Zip
Check if New Address
Work E-mail
Personal E-mail
Work Phone
Home Phone
3. Domestic Partner Information
Last Name
First Name
MI
Date of Eligibility for Coverage
Date of Birth
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
You must report to your employer's benefits administrator within 31 days after a person enrolled as your spouse, domestic partner or
dependent child becomes ineligible for benefits. If you make this report on time, the change will be effective the first of the month
after your report. If you do not report this change on time, OEBB may consider that an intentional misrepresentation of a material
fact, for which OEBB may terminate the family member’s coverage effective the first of the month after eligibility was lost.
107000-00601 (rev. 12/1/2010)
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