Domestic Partnership: Affidavit Form

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CHABOT­LAS POSITAS COMMUNITY COLLEGE DISTRICT
Office of Human Resources
Domestic Partnership: Affidavit
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE 
OF  CALIFORNIA THAT THE STATEMENTS BELOW ARE TRUE AND CORRECT. 
We have an intimate, committed relationship of mutual caring; 
1. 
We live together (see definition on the next page); 
2. 
We agree to be responsible for each other's basic living expenses (see definition on the next 
3. 
page) during our domestic partnership; we also agree that anyone who is owed these 
expenses can collect from either of us; 
We are both 18 or older; 
4. 
Neither of us is married; 
5. 
Neither of us is related to the other; 
6. 
Neither of us has a different domestic partner now; 
7. 
8. 
Neither of us has had a different partner in the last six months (this last condition 
does not apply if you had a partner who died; if you did, cross this out). 
We declare under penalty of perjury under the laws of the State of California that the 
statements above are true and correct. 
(Please Print) 
Date: ____/____/____ 
Employee’s Name: _______________________________________________________ 
(Last)                                           (First)                                          (Middle) 
Domestic Partner’s Name: _________________________________________________ 
(Last)                                           (First)                                          (Middle) 
Shared Residence Address:
____________________________________________________________ 
(Street & Number)                              (City)                         (State/Zip) 
Employee's Signature: ________________________________ Signed on: ____/____/____ 
Domestic Partner’s Signature: __________________________Signed on: ____/____/____ 
Updated 06/2008; 3/21/13 
P:/FORMS/Faculty 2007­08/DomesticPartnershipAffidavit­Updtd.doc 

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