Affidavit Of Domestic Partnership Form (Page 2 of 2) in pdf

4. Declaration of Domestic Partnership and Employee Signature

, certify that

(print name of employee)

(print name of domestic partner)

and I are, and have been, each other’s partner in a domestic partnership, as defined below. For the purposes of

this affidavit, a “domestic partnership” is one consisting of two persons in which the following applies:

1. Both are at least 18 years of age;

2. Are responsible for each other’s welfare and are each other’s sole domestic partner;

3. Are not married to anyone and either has not had a spouse or another domestic partner within the prior

six months. If previously married, the six-month period starts on the final date of divorce;

4. Share a close personal relationship and are not related by blood closer than would bar marriage in the

State of Oregon;

5. Have jointly shared the same regular and permanent residence for at least six months; and

6. Are jointly financially responsible for basic living expenses defined as the cost of food, shelter and any

other expenses of maintaining a household. Financial information must be provided if requested.

This affidavit terminates upon the death of the signing member’s domestic partner or by a change in

circumstances attested to in this affidavit. The signing member must notify their Educational Entity within 31

days after such death or change, by completing a Termination of Domestic Partnership form and a midyear

change form. After submitting the forms, the member 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 Educational Entity.

Note: Your Educational Entity will calculate and apply applicable imputed value tax for

domestic partners covered under OEBB benefit plans.

We certify that the foregoing is true and accurate to the best of our knowledge.

_______________________________________________

_______________________

Employee Signature

Date

_______________________________________________

_______________________

Domestic Partner Signature

Date

_______________________________________________

_______________________

Educational Entity Staff (Received by)

Date

Submit completed affidavit to your Educational Entity. Do not mail this form to OEBB.

107000-00601 (rev. 12/1/2010)

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Affidavit Of Domestic Partnership Form Page 2