June 2010
Declaration of Domestic Partnership
DOMESTIC PARTNER means a person in a domestic partnership with an employee or annuitant of the
same sex.
DOMESTIC PARTNERSHIP means a committed relationship between two adults, of the same sex, that
meets all of the requirements below.
We attest and declare that the following statements (A through G) are true and correct:
A.
We are each other’s sole domestic partner and intend to remain so indefinitely;
B. We have a common residence and intend to continue the arrangement indefinitely;
C. We are at least 18 years of age and mentally competent to consent to contract;
D. We share responsibility for a significant measure of each other’s financial obligations;
E. Neither of us is married (legally or by common law) to, or legally separated from, anyone else;
F. Neither of us is a domestic partner of anyone else; and,
G. We are not related in a way that, if we were of opposite sexes, would prohibit legal marriage in the
State in which we reside.
We also agree to, and understand that:
1. We must inform the appropriate employing agency or retirement system of the dissolution of this
domestic partnership (which includes the death of either partner) not later than 30 days after we
no longer meet the definition of Domestic Partnership;
2. Either domestic partner may inform the employing agency or retirement system of the dissolution
of the domestic partnership; and,
3. Willful falsification of information within this document may lead to disciplinary action, loss of
insurance coverage, and/or the recovery of the cost of benefits received related to such falsification.
PRINTED Name of Employee/Annuitant
Last name First name M.I.
Signature of Employee/Annuitant
Date Signed
/ /
Social Security number or Other Employee Identifier
Civil Service Retirement number (CSA or CSF), if applicable
PRINTED Name of Domestic Partner
Last name First name M.I.
Signature of Domestic Partner
Date Signed
/ /
Date Domestic Partnership was formed
/ /
To complete the registration of this Domestic Partnership, you must file this form with your current
employing agency or retirement system. Please keep a copy for your own records.
AGENCY/RETIREMENT SYSTEM RECEIPT
Name and signature of agency/retirement system official and date or official date stamp or other means by
which the agency or retirement system indicates official receipt:
Name
Signature Date
/ /
