Sample Affidavit Of Marriage Domestic Partnership printable pdf download

Sample Affidavit Of Marriage Domestic Partnership

SAMPLE AFFIDAVIT OF MARRIAGE/DOMESTIC PARTNERSHIP

SECTION I

I, __________________________________ certify that (Complete either “A” or “B”):

Name of Employee (Print)

I, and ________________________ were legally married on _____________________.

Name of Spouse (Print)

Date of Marriage (Print)

-OR-

I, and ________________________ are domestic partners, and we:

Name of Domestic Partner (Print)

Share the same regular and permanent residence; and

Have a close, personal relationship; and

Are jointly responsible for “basic living expenses”, as defined below; and

Are not married to anyone; and

Are each eighteen (18) years of age or older; and

Are not related by blood closer than would bar marriage in the State of

______________________________________ ; and

Were mentally competent to consent to contract when our domestic partnership

began; and

Are each other’s sole domestic partner and are responsible for each other’s

common welfare.

“Basic living expenses” means the cost of basic food, shelter, and any other expenses of a

Domestic Partner which are paid at least in part by a program or benefit for which the partner

qualified because of the Domestic Partnership. The individuals need not contribute equally or

jointly to the cost of these expenses as long as they agree that both are responsible for the cost.

SECTION II

I understand that this affidavit shall be terminated upon the death of my spouse/domestic

partner or by a change of my circumstance attested to in this affidavit.

I agree to notify my payroll/personnel representative if there is any change of

circumstances attested to in this affidavit with thirty (30) days of change by filing a

Statement of Termination of Marriage/Domestic Partnership.

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Rev 5/26/04

Sample Affidavit Of Marriage Domestic Partnership