Domestic Partnership: Affidavit Form Page 2
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Domestic Partnership: Affidavit
DEFINITIONS:
"Live together" means that the domestic partners share a place to live.
"Basic living expenses" means the cost of basic food and shelter. It also includes
any other expense, which is paid by a benefit either partner receives because of
the partnership. For example, domestic partners who receive health insurance
coverage are mutually responsible for medical bills, which the insurance does not
pay. It is not necessary to actually split basic living expenses to be domestic
partners. The partners just have to agree to provide these things for their partner if
the partner is unable to provide for him or herself.
THE LAST STEP:
To complete setting up a domestic partnership, you must sign this form in front
of a Notary Public, have the Notary fill in the notarization at the bottom of this page,
and submit the Affidavit to the Office of Human Resources, 7600 Dublin Boulevard,
rd
3
Floor, Dublin CA 94568.
NOTARIZATION:
State of ________________________________, County of __________________
on
before me,__________________________________________
____/____/____
Date
Name and Title of Officer (e.g., "Jane Doe, Notary Public")
Personally appeared:
________________________________________________________________
Name(s) of Signers
Who proved to me on the basis of satisfactory evidence to be the person (s) whose
name(s) is/are subscribed to the within instrument and acknowledged to me that
he/she/they executed the same in his/her/their authorized capacity(ies), and that by
his/her/their signature(s) on the instrument the person(s), or the entry upon behalf of
which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California
that the foregoing paragraph is true and correct.
WITNESS my hand and official seal,
Signature of Notary Public _____________________________________________
Reference:
Article 20A.3, 20A.3b – Faculty Collective Bargaining Agreement
Updated 06/2008; 3/21/13
P:/FORMS/Faculty 200708/DomesticPartnershipAffidavitUpdtd.doc
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