The undersigned, being duly sworn, depose and declare as follows:
We are both eighteen (18) years of age or older and are mentally competent to consent to
contract. If either or both of us has been married, we must submit evidence of the termination of
the marriage.
We are not related by blood in a manner that would bar marriage under the laws of the State. We
have been living together on a continuous basis prior to the date of this affidavit.
One of us is enrolled in an employer group health insurance program.
Neither of us has been registered as a member of another domestic partnership within the last six
(6) months.
I, the enrollee, affirm that I will file a Termination of Domestic Partnership Form within 30 days of the date my
partner no longer meets one or more of the qualifying criteria set forth above.
I, the enrollee, understand that any false or misleading statements made in order to receive benefits for
which I do not qualify will subject me to financial responsibility for any benefits paid on behalf of my partner
and/or other legal actions appropriate to the prosecution of insurance fraud.
__________________________________ _______________________________
Print Name (employee enrollee) Print Name (Partner)
__________________________________ ________________________________
Address Address
__________________________________ ________________________________
City State Zip City State Zip
__________________________________ ________________________________
Employee Signature Partner Signature
State of __________________
County of _________________
Signed and sworn before me on __________ (date)
Signature of Notary ___________________________
My commission expires ____________ (date)
Certificate # _____________
Proof of Cohabitation
You are required to submit proof that you and your partner reside together. The proof may be one
document with both names or two separate documents that show the residence of each partner. The following is a
list of items that can be used to demonstrate proof of residency.
Submit (1) of the following documents:
Auto Registration
Bank Statement
Drivers License
Lease agreement listing both parties
Mortgage agreement listing both parties
Tax return
Utility bill (gas bill, electric bill, water bill)
Proof of Financial Interdependence
You must submit two (2) copies of clearly unaltered documents as proof of financial interdependence. Below
is a
list of acceptable proofs.
Submit (2) of the following documents:
Certificate of a joint bank account
Joint obligation on a loan
Joint ownership of holdings or investments
Joint ownership of real estate other than residence
Joint credit card or charge card
Utility bill (gas, electric, etc.)
Designation of Beneficiary under policy (retirement, life insurance, etc.)
Joint ownership of residence
Joint ownership of motor vehicle
Joint responsibility for child care (guardianship, school documentation)
Shared rental payments (payments need not be 50/50)
Listing of both partner’s names on a lease or shared rental payments, for property other than
Execution of wills naming partner as executer and/or beneficiary
Mutual grant of durable power of attorney