Declaration Of Domestic Partnership
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1Declaration of Domestic Partnership
The Federal Long Term Care Insurance Program
“Domestic partner” means a person in a domestic partnership with an employee, annuitant, member of the uniformed
services, or retired member of the uniformed services.
“Domestic partnership” means a committed relationship between two adults, of the opposite or same sex, in which
the partners meet all of the requirements below.
We attest and declare that all of the following statements are true and correct.
f
We are each other’s sole domestic partner and intend to remain so indefinitely.
f
We maintain a common residence and intend to continue to do so (or would maintain a common residence
but for an assignment abroad or other employment-related, financial, or similar obstacle).
f
We are at least 18 years of age and mentally competent to consent to a contract.
f
We share responsibility for a significant measure of each other’s financial obligations.
f
We are not married or joined in a civil union to anyone else.
f
We are not a domestic partner of anyone else.
f
We are not related in a way that would prohibit legal marriage in the U.S. jurisdiction in which
the domestic partnership was formed.
We also agree to and understand that:
f
We must notify the appropriate employing agency, military branch, or retirement system if, at any time between
the time of application and the time coverage is scheduled to go into effect, we no longer meet the definition of
domestic partnership, in which case our domestic partnership is deemed terminated. We understand that such
notification must be made as soon as possible, but in no event later than 30 calendar days after our domestic
partnership is terminated.
f
Willful falsification of information within this document may lead to disciplinary action and the recovery
of the cost of benefits received related to such falsification, and may also constitute a criminal violation
under 18 U.S.C. 1001.
Please fill out the information below.
Name of employee or annuitant
First name
M.I.
Last name
Signature of employee or annuitant
/
/
Date signed
(mm/dd/yyyy)
Social Security number or other identifier
Civil service retirement number (CSA or CSF), if applicable
Name of domestic partner
First name
M.I.
Last name
Signature of domestic partner
/
/
/
/
Date signed
Date domestic partnership was formed
(mm/dd/yyyy)
(mm/dd/yyyy)
To complete the registration of this domestic partnership, you must file this form with your current employing agency,
military branch, or retirement system. Please keep a copy for your own records.
Agency, military branch, or retirement system receipt
Name and signature of agency, military branch, or retirement system official and date or official date stamp or other
means by which the agency, military branch, or retirement system indicates official receipt:
Name
/
/
Signature
Date
(mm/dd/yyyy)
DP v. 2 0815
August 2015
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