Affidavit Of Marriage/same-Sex Domestic Partnership - Johns Hopkins University printable pdf download

JOHNS HOPKINS

School of Medicine

COMPLETE ONLY IF ENROLLING SPOUSE OR SAME

SEX DOMESTIC PARTNER FOR HEALTH INSURANCE

AND

OR DENTAL INSURANCE

JOHNS HOPKINS UNIVERSITY

AFFIDAVIT OF MARRIAGE/SAME-SEX DOMESTIC PARTNERSHIP

I, _____________________________ SSN _____-______-______ certify that I and

Name of Subscriber (print)

(Complete either “A” or “B”):

“A” _______________________SSN _____-_____-_____were legally

Name and SSN of Spouse (print)

married on ___/___ /____

-OR-

“B” __________________________SSN _____-_____-_____became

Name and SSN of Same-sex Domestic Partner (print)

same-sex domestic partners on ___/___ /____, and we certify the following to be true:

We are committed as a family in a long-term relationship of indefinite duration and are socially,

emotionally, and financially interdependent with each other in an exclusive mutual commitment in

which we agree to be responsible for each other’s common welfare and share financial obligations;

and

2. we are not related by blood to a degree of closeness which would prohibit legal marriage in the state in

which we legally reside and our relationship does not violate state or local law; and

3. we agree to notify Johns Hopkins University School of Medicine Registrar’s Office if there is any

change in our status of marriage or domestic partnership as certified in this statement within thirty days

of that change by filing a Marriage/Same-sex Domestic Partnership Termination Form; and

4. we were competent to consent to contract when our marriage or domestic partnership began; and

5. we understand that any marriage or domestic partnership recognized by the University based on this

affidavit will be treated as terminated for benefits purposes upon the death of my spouse/domestic

partner or on the date indicated in a Marriage/Same-sex Domestic Partnership Termination Form

submission (or, if earlier, on the date of divorce or legal separation of a legal marriage); and

6. we understand that benefits provided by Johns Hopkins University School of Medicine for a domestic

partner or a child of a domestic partner generally will be subject to federal (and possibly state) income

tax withholding and also to Social Security and Medicare taxes based on the fair market value of those

benefits and any employee contributions for coverage for those benefits must be made on an after-tax

basis unless the subscriber signs the statement at the end of this Affidavit to certify that the partner or

child qualifies as a Section 152 Dependent (as described later in this Affidavit) of the subscriber for tax

purposes; and

7. we understand that this information will be held confidential but is subject to disclosure for administrative

purposes, as required by law or upon our express written authorization; and

8. we understand that any person’s eligibility for benefits is subject to auditing by Johns Hopkins University

School of Medicine and its agents for verification purposes; and

9. we understand that legal implications under state and/or federal law may exist due to the declaration of

responsibility for our common welfare; and

10. we understand that if we make a false statement or misrepresentation on this Affidavit of

Marriage/Same-sex Domestic Partnership, the University reserves the right to take any and all actions

necessary to deny benefits or to recover amounts paid for benefits to which a person was not entitled,

as well as any expenses or attorney fees incurred by the University in an attempt to recover such

amounts and that any false statements on this Affidavit may lead to other disciplinary action, up to and

including termination of employment.

11. we understand that completing this Affidavit is only one requirement for certain benefits and that all

eligibility requirements and other provisions of all benefit plans as well as policy provisions of University

programs will also apply.

(OVER)

Affidavit Of Marriage/same-Sex Domestic Partnership - Johns Hopkins University

Related Articles

Related forms

Related Categories