Affidavit of Domestic Partnership/

Dependent Tax Certification

If you are in a legal domestic partner relationship and would like to cover your domestic partner and / or eligible child(ren) under a McDonald’s or HMO health, dental or vision plan, please complete the below form.

Employee Information / Last First Middle
NAME: / EMPLOYEE #: ______
Your employee # can be found on the top right corner of your pay stub.
ADDRESS:
CITY: / STATE: / ZIP CODE:
DAYTIME TELEPHONE #: ( ) -
Domestic Partner Information / NAME:
DOMESTIC PARTNER’S (MONTH/DAY/YEAR)
DATE OF BIRTH: MALE □ FEMALE □ / PHONE #: ( ) -
Certification of Partnership / I certify that my partner and I are domestic partners and we:
  1. are in a mutually exclusive relationship, are each other’s sole domestic partner, have been so for at least six months and intend to remain so indefinitely;
  2. are both at least 18 years of age (or at least age of consent in the state in which we live);
  3. are not related closely enough by blood to bar marriage in the state in which we reside;
  4. reside together in the same principal residence, have done so for at least the past six months and intend to do so indefinitely;
  5. have joint responsibility for each other’s welfare and financial obligations and can upon request show evidence of such responsibility in two of the following forms:
  • registration in a state or locality that allows for registration of domestic partners, or
  • joint mortgage, lease or deed, or
  • joint bank account or credit cards, or
  • designation of the domestic partner as beneficiary for life insurance, retirement benefits, will or trust, or
  • durable property or health care power of attorney.
I understand that I am obligated to file a Notice of Termination of domestic partnership with the Service Center within 31 days of the date on which we no longer meet the criteria for a domestic partnership. I further understand that acknowledging our domestic partner relationship in this statement may subject us to tax or other legal obligations and that I should consult our attorney and/or tax advisor.
Dependent Tax Certification / I have consulted with my tax advisor or understand the requirements for qualifying another person as my “dependent” for federal income tax purposes.* I certify that for the next calendar year and future years the information provided below is accurate and true:
My Domestic Partner qualifies as my dependent for federal income tax. / YES ______NO ______
Indicate which statement is true: (please only choose one)
Allof my dependent children qualify as my dependents for federal income tax.
Some of my dependent children qualify as my dependents for federal income tax.
Noneof my dependent children qualify as my dependents for federal income tax.
I agree that I will contact the Service Center immediately to complete a new Dependent Tax Certification Form as soon as there is a change in that family member’s status as my dependent for federal income tax purposes. I understand that until I make such a status change, McDonald’s will rely on this certification for the tax treatment of benefits for my Domestic Partner and covered children.
Signature / EMPLOYEE SIGNATURE: / DATE:
DOMESTIC PARTNER TAX IMPLICATIONS
Note: If you cover a domestic partner, the portion of your premium for your partner and any children is deducted from your pay after taxes, and you pay taxes on the value of the company’s contribution for their coverage.
However, if you complete an Affidavit of Domestic Partnership/Dependent Tax Certification form to certify the family members that qualify as your dependents for federal income tax purposes, your premiums for the coverage of those family members will be taken pre-tax, and the company-paid portion of their coverage will not be treated as taxable income to you.
Should you have questions about the domestic partner tax implications, please contact your financial advisor before enrolling your domestic partner and/or eligible dependent children into a McDonald’s health, dental or vision plan.
Important: additional Surcharge COSTS MAYalso apply when covering a domestic partner.

Please forward this completed form and all required attachments (if applicable) to:

McDonald’s Service Center Dept. 28, McDonald’s Corporation, 2111 McDonald’s Drive, Oak Brook, IL 60523

Telephone #: (877) 623-1955 Fax#: (630) 623-5027 E-mail address:

To confirm receipt of your documents please contact the Service Center. Representatives are available M – F 8:00am – 5:00pm CT, excluding holidays.

FORM 38381/1/2017

*See the explanation of who is a dependent in IRS Publication 502 at