Declaration Form Of Domestic Partnership Page 3
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3employee, b) upon request of the insurer or plan administrator, or c) if
otherwise required by law.
3. We understand that this Declaration may have legal implications relating, for
example, to our ownership of property or to taxability of benefits provided, and
that before signing this Declaration we should seek competent legal advice
concerning such matters.
We affirm, under penalty of perjury, that the statements in this Declaration are
true and correct.
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Employee Signature
DOB
Date
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Domestic Partner Signature
DOB
Date
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Employee & Domestic Partner Address
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