Affidavit Of Domestic Partnership
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1
2AFFIDAVIT OF DOMESTIC PARTNERSHIP
Declaration
We, ________________________________ (Enrollee) and ________________________________
(Domestic Partner) certify that we are domestic partners in accordance with the following criteria and
affirm that on or about __________________________, _______, we entered into a Domestic
Partner relationship and are living together in a Domestic Partner relationship.
Domestic Partner Criteria
We declare, under penalty of perjury that we meet all of the following criteria:
•
We are eighteen years of age or older and unmarried; and
•
We are of the same sex as each other; and
•
We are not related by blood in any manner that would prohibit legal marriage; and
•
We have assumed mutual obligations for the welfare and support of each other; and
•
We have been sharing a common residence and living together as a couple in the same
household; and
•
We are each other’s sole domestic partner.
Change in Domestic Partner Status
We acknowledge that, in the event we no longer meet one or more of the criteria set forth above, we
will no longer be considered Domestic Partners and will immediately file an Affidavit of Termination of
Domestic Partnership form with the BSA Benefits Office. The Partner, and any dependents of the
Domestic Partner will no longer be eligible for coverage under the BSA benefits programs, but may
elect temporary continuation of coverage under the continuation of coverage provisions of COBRA.
Other Acknowledgements
We declare, under penalty of perjury, that all of the information we have provided on this form is true
and correct.
I, the Enrollee, understand that any false or misleading statement made in order to receive benefits for
which I do not qualify will subject me to financial responsibility for any benefits paid on behalf of my
domestic partner and such partners’ dependents and disciplinary action up to and including
termination of employment and possible charges of fraud.
Employee Information
Domestic Partner Information
_______________________________
_______________________________
_
_
Name (printed)
Name (printed)
_______________________________
_______________________________
_
_
Social Security Number
Social Security Number
_______________________________
_______________________________
_
_
Date of Birth
Date of Birth
_______________________________
_______________________________
_
_
Street Address
Street Address
_______________________________
_______________________________
_
_
City, State, Zip Code
City, State, Zip Code
_______________________________
_______________________________
_
_
Signature
Signature
_______________________________
_______________________________
_
_
Date Signed
Date Signed
_________________________
_________________________
State of
_
State
___
_________________________
_________________________
County of
County of
Sworn to before me this day of
Sworn to before me this day of
_____________________
_________
_____________________
_________
, 20
, 20
Notary Public
Notary Public
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