Confidential
Wittenberg University
AFFIDAVIT OF SAME-SEX DOMESTIC PARTNERSHIP
Employee InformationEmployee Name (Last, First, Middle):
Date of Birth / Gender / Social Security Number
Address: / City / State / Zip
Domestic Partner Information
Name (Last, First, Middle): / Partnership Began On:
Date of Birth / Gender / Social Security Number
Address: / City / State / Zip
SAME-SEX DOMESTIC PARTNERSHIP DECLARATION
We, the undersigned, declare that we are two individuals of the same sex who, together, meet each of the following criteria:
1. Are eighteen (18) years of age or older,
2. Are competent to enter into a contract
3. Are not legally married to or legally separated from, nor the domestic partner of, any other person
4. Are not related by blood closer than permitted under marriage laws of the State of Ohio
5. Are living together and intend to do so indefinitely, and
6. Are in a relationship that is an exclusive mutual commitment meaning we:
a. Are financially interdependent;
b. Are jointly responsible for ‘basic living expenses’ including each other’s debts; and
c. Are jointly responsible for each other’s common welfare and mutual fidelity
7. Have been living together as a couple for at least twelve (12) months prior to submitting this Affidavit and enrolling for Domestic Partner Benefits, and
8. Intend to continue the domestic partner relationship indefinitely, while understanding the relationship is terminable at the will of either partner.
In order to demonstrate proof of our financial interdependence, we have included documentation evidencing at least (3) three categories of financial interdependence, one of which must be proof of common ownership of real property (joint deed or mortgage agreement) or of a common leasehold interest in residential property. Other documentation that satisfies this requirement includes the following:
[proof of common ownership of a motor vehicle]
[proof of joint bank accounts or credit accounts]
[proof of the employee’s designation of the same-sex domestic partner as the employee’s primary beneficiary designation under the employee’s life insurance or retirement benefits;]
[proof of the employee’s designation of the same-sex domestic partner as the employee’s beneficiary designation under the employee’s will]
[proof of the employee’s assignment of a durable power of attorney for property and financial affairs or a durable power of attorney for health care to the employee’s same-sex domestic partner.
Domestic Partner Dependent Child Information (List only the domestic partner’s unmarried
child(ren) who are in the custody and care of the domestic partner and a member of the employee’s household.)
Dependent Child Name (Last, First, Middle): / Social Security Number / Date of Birth / Sex / Married / Full-timeStudent
M / F / Y / N / Y / N
M / F / Y / N / Y / N
Tax Dependent Information
Is the domestic partner or domestic partner’s child(ren) a qualified tax dependent of the employee?
(Circle One) Y* N If Yes, please complete the Certification of Tax-Qualified Dependents form.*
ACKNOWLEDGEMENTS
1. We understand that the value of coverage provided to the domestic partner and the domestic partner’s children (e.g., Wittenberg University’s cost for providing domestic partner benefits less the employee’s payroll contribution) will generally be taxable income to the employee unless the domestic partner and partner’s children are qualified tax dependents of the employee.
2. The employee is responsible for notifying the University’s Department of Human Resources within fifteen (15) calendar days after the date that any one of the declared statements in this Affidavit is no longer true. The employee must provide this notice by submitting a Termination of Domestic Partnership form to the Department of Human Resources. We understand that eligibility for domestic partner benefits ends on the day that we no longer meet each of the eligibility requirements listed in the University’s’ Domestic Partnership policy, and any benefits paid in error following the date of ineligibility will be recovered by the university in accordance with the terms of each benefit plan.
3. This affidavit is requested for the purpose of Wittenberg University making a determination of our eligibility for domestic partner benefits.
4. We understand that the university may terminate or change benefit coverage or eligibility at any time.
5. To the extent any documentation evidencing financial interdependence submitted with this Affidavit is no longer valid or becomes materially inaccurate while we are receiving domestic partner benefits, we will submit additional documentation of financial interdependence to the Department of Human Resources so that at least three (3) forms of proof of our financial interdependence are on file with the University at all times. The University may ask for additional information related to continuing financial interdependence from time to time, and we agree to cooperate with such requests.
CERTIFICATION
We certify that the forgoing information is true and correct and understand that a false declaration of a domestic partnership or failure to update proof of financial interdependence or failure to file a timely notice of Termination of Domestic Partnership with Wittenberg’s Human Resources Department may result in disciplinary action up to and including termination of employment at Wittenberg University. We agree that in the event of a false declaration, or the failure to update proof of financial interdependence or failure to file a Termination of Domestic Partnership form with the university, Wittenberg University may recover damages (including benefits paid in error) from either or both of us and all costs and expenses incurred by the university as a result, including, without being limited to, attorneys’ fees incurred by the university to recover such damages.
______
Employee Signature Date Domestic Partner Signature Date
NOTARIZATION: STATE OF ______COUNTY OF ______
The foregoing affidavit was acknowledged before me this ______day of ______, 20______,
By: ______, Notary Public My Commission Expires: ______