Affidavit Of Domestic Partnership (Page 2 of 2) in pdf

Affidavit Of Domestic Partnership Page 2

DEPENDENT TAX AFFIDAVIT

FOR ENROLLING A DOMESTIC PARTNER IN THE BSA HEALTHCARE PROGRAMS

Declaration

I, _____________________________ (Enrollee), certify that my domestic partner,

___________________________ (Domestic Partner), fully qualifies as my dependent under

Internal Revenue Code (IRC) Section 152(a)(9).

In addition, the following child(ren) of such Partner fully qualify as my dependent under

Internal Revenue Code (IRC) Section 152(a)(9).

_________________________________________________ (Domestic Partner’s Child 1)

_________________________________________________ (Domestic Partner’s Child 2)

_________________________________________________ (Domestic Partner’s Child 3)

_________________________________________________ (Domestic Partner’s Child 4)

I understand that if my partner’s dependent status or the status of such Partner’s child(ren)

under IRC Section 152(a)(9) changes at any time during the year, I will be responsible for

reporting and paying tax on any resulting imputed income. If this should occur, I will notify

the BSA Benefits Office immediately.

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

_________________________________

Name (printed)

_________________________________

Social Security Number

_________________________________

Signature

_________________________________

Date Signed

___________________________

State of

__________________________

County of

Sworn to before me this day of

____________________

__________

, 20

_________________________________

Notary Public

Affidavit Of Domestic Partnership Page 2