Domestic Partnership: Affidavit Form
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1
2CHABOTLAS POSITAS COMMUNITY COLLEGE DISTRICT
Office of Human Resources
Domestic Partnership: Affidavit
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE
OF CALIFORNIA THAT THE STATEMENTS BELOW ARE TRUE AND CORRECT.
We have an intimate, committed relationship of mutual caring;
1.
We live together (see definition on the next page);
2.
We agree to be responsible for each other's basic living expenses (see definition on the next
3.
page) during our domestic partnership; we also agree that anyone who is owed these
expenses can collect from either of us;
We are both 18 or older;
4.
Neither of us is married;
5.
Neither of us is related to the other;
6.
Neither of us has a different domestic partner now;
7.
8.
Neither of us has had a different partner in the last six months (this last condition
does not apply if you had a partner who died; if you did, cross this out).
We declare under penalty of perjury under the laws of the State of California that the
statements above are true and correct.
(Please Print)
Date: ____/____/____
Employee’s Name: _______________________________________________________
(Last) (First) (Middle)
Domestic Partner’s Name: _________________________________________________
(Last) (First) (Middle)
Shared Residence Address:
____________________________________________________________
(Street & Number) (City) (State/Zip)
Employee's Signature: ________________________________ Signed on: ____/____/____
Domestic Partner’s Signature: __________________________Signed on: ____/____/____
Updated 06/2008; 3/21/13
P:/FORMS/Faculty 200708/DomesticPartnershipAffidavitUpdtd.doc
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