Declaration
of
Domestic
Partnership:
Federal Employees Health Benefits (FEHB) Program
DOMESTIC PARTNER means a person in a domestic partnership with an employee 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 H) 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, legally separated from, or joined in a civil
union with anyone else;
F.
Neither
of us is
a domestic partner
of
anyone
else;
G.
We are not related in
a
way that,
if
we were of opposite sex, would prohibit legal marriage as of the day
before
the current open season,
or;
H.
Either (select applicable
situation):
□
For Stepchildren to be Covered Effective in January 2014, or Other Open Season Enrollments
or
Changes:
We would marry but for the state
of
our residence [____] to permit same-sex marriage as of
the
day before the current open season,
or; STATE
□
For Stepchildren to be Covered as
a
Qualifying Life Event:
We would marry but for the state
of our
residence [____] to permit same-sex marriage as of the date
I
am signing this
declaration.
STATE
We also agree to, and understand
that:
1.
We
must inform
the tribal employer
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 tribal employer
of
the
dissolution of
the domestic
partnership;
3. A child's continued eligibility for FEHB coverage as a stepchild who is the child of a same
sex domestic partner must be determined on an annual basis at Open Season. We
understand that, should the laws in our state of residence change prior to the next Open
Season to permit same sex couples to marry, or if we move to a state that permits same sex
marriage, and we choose not marry, we will inform the tribal employer that our child's
coverage must be terminated for the following plan year;
and,
4. 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
Last
name First name M.I.
Signature
of
Employee
Date
Signed
/
/
Social Security number
or
Other Employee
Identifier
