AFFIDAVIT OF DOMESTIC PARTNERSHIP
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
NOTARY PUBLIC:
State of __________________
County of _________________
Signed and sworn before me on __________ (date)
Signature of Notary ___________________________
My commission expires ____________ (date)
Certificate # _____________
Stamp/Seal:
