Home Address
Domestic Partner
Home Address
Identification #
Social Security #
Birth Date
Social Security #
Birth Date
We the undersigned attest to the following:
each party is the sole domestic partner of the other;
each party is at least eighteen (18) years of age or older and competent to enter into a contract in the state in
which he or she resides;
both parties currently share a common legal residence and have shared said residence for at least six (6) months
prior to application for domestic partner coverage;
neither party is married, a party to a Civil Union, or related to the other by adoption or blood to a degree of closeness that
would bar marriage/Civil Union in the state in which they legally reside;
both parties are in a relationship of mutual support,caring, and commitment and intend to remain in such a
relationship in the indefinite future;
the parties are jointly responsible for basic living expenses (basic living expenses are defined as the cost of basic
food, shelter, and any other expenses of the common household; the partners need not contribute equally or jointly
to the payment of these expenses as long as they agree that both are responsible for them); and
neither party filed a Termination of Domestic Partnership within the preceding nine months.
We declare that all the foregoing information provided by us is true and correct and that all provisions of this
Statement have been met.
We understand that:
any entities or persons (including, but not limited to, Blue Cross and Blue Shield of Vermont) who suffer any loss
because of any false statements contained in this Statement may bring a civil action suit against us to recover their
respective losses, including reasonable attorneys fees;
if there is any change in the information certified in the Statement of Domestic Partnership that would make the
domestic partner ineligible, the employee must complete and file a Termination of Domestic Partnership form
within 30 days of the changes; and
Note to Group: Keep a copy of this document for your records and forward the original Statement attached to an
appropriate Group Application and Change Form.
Employee Signature
Domestic Partner Signature
On this day of
,20 before me personally appeared
, to me
known to be the persons described herein, and who executed the foregoing, and swore to its truth.
Before me,
Notary Public Signature and Commission Exp. Date
280.77 (06/03)
the effective date of coverage for the domestic partner and any initially eligible dependents of the domestic
partner is:
on the open enrollment date if Blue Cross and Blue Shield of Vermont receives the Statement of Domestic
Partnership and application form before your group open enrollment date; or
the first of the month following the group open enrollment date if Blue Cross and Blue Shield of Vermont
receives the Statement of Domestic Partnership and application form during the month in which the groups
open enrollment date occurs.
We agree to notify the employer if our domestic partnership no longer meets the criteria established herein.
If required, attached to this document is the following documentation in support of this Statement of Domestic
proof of common residence—e.g.,drivers licenses showing same address, passports or designations for receipt
of mail; and
proof of financial interdependence—e.g., joint checking, savings or credit card statements, executed powers of
attorney, insurance policies, and/or copies of designated signatures on safety deposit boxes.