Declaration Form Of Domestic Partnership


Declaration Of Domestic Partnership
We, ____________________ and ____________________, each
(employee-print name)
(domestic partner-print name)
certify and declare that we are domestic partners in accordance with the
following criteria:
1. We affirm that this domestic partnership began on or about __/__/__.
2. We are each other's sole domestic partner, and we intend to remain so
3. Neither of us is married to or legally separated from anyone else nor have
had another domestic partner within the prior six months.
4. We are both at least eighteen (18) years of age and mentally competent to
consent to contract.
5. We are not related by blood to a degree of closeness that would prohibit legal
marriage in the state in which we legally reside.
6. We cohabit and reside together in the same residence and intend to do so
indefinitely. We have resided in the same household for at least six months.
7. We are engaged in a committed relationship of mutual caring and support and
are jointly responsible for our common welfare and living expenses. Our
interdependence is demonstrated by at least three of the following (please
check appropriate items):
___ Common ownership of real property (joint deed or mortgage
agreement) or a common leasehold interest in property
___ Common ownership of a motor vehicle
___ Driver's license listing a common address
___ Proof of joint bank accounts or credit accounts
___ Proof of designation as the primary beneficiary for life insurance or
retirement benefits, or primary beneficiary designation under a
partner's will
___Assignment of a durable property power of attorney or health care
power of attorney
8. We are not in this relationship solely for the purpose of obtaining benefits


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