U.S. Department of State
For the purposes of obtaining benefits and assuming obligations under the Foreign Affairs Manual (FAM) and
Department of State Standardized Regulations (DSSR), I, ,
declare that I and :
Name of Employee
Full Name of Domestic Partner
(1) are each other's sole domestic partner and intend to remain committed to one another indefinitely;
(a) have a common residence, and intend to continue the arrangement; or
(b) have had a common residence and intend to resume having a common residence after an
assignment abroad for which my domestic partner did not accompany me; or
(c) would have a common residence, but are prevented from having one for the following
(3) are at least 18 years of age and mentally competent to consent to contract;
(4) share responsibility for a significant measure of each other's common welfare and financial
(5) are not married to, joined in civil union with, or domestic partners with anyone else; and
(6) are same-sex domestic partners, and not related in a way that would prohibit legal marriage in the
State in which we reside.
I further declare that I,
Name of Employee
(7) agree to file a statement of dissolution of the domestic partnership not later than 30 days after the
death of my domestic partner or the date of dissolution of the domestic partnership;
(8) understand that my domestic partner will be held to standards of conduct in the FAM that apply to
family members; and
(9) understand that falsification of information within this affidavit may constitute a criminal violation
under 18 U.S.C. 1001 and may lead to disciplinary action.
Signature of Employee
Name of Employee
Date (mm-dd-yyyy)
¹ If the employee cannot certify to the "common residence clause" except by filling in clause 2(c), the domestic partner relationship does
not qualify for benefits and obligations under the FAM and DSSR unless and until, after review of the employee's description, the Under
Secretary of State for Management or his or her designate determines that the circumstances described are sufficient to justify the waiver of
the common residency requirement.
3 FAM 1610
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