Declaration Form Of Domestic Partnership printable pdf download

Declaration Form Of Domestic Partnership

Declaration Of Domestic Partnership

DECLARATION:

We, ____________________ and ____________________, each

(employee-print name)

(domestic partner-print name)

certify and declare that we are domestic partners in accordance with the

following criteria:

II.

STATUS

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

indefinitely.

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

coverage.

Declaration Form Of Domestic Partnership