Domestic Partner Declaration

We, the undersigned, are both over 18 years of age, we are in agreement about when our domestic partnership began, we have cohabited for a minimum of 12 months and throughout this period the partner has been publicly represented as the Staff Members partner, we are the sole domestic partner of each other and have no other domestic partners, we are not related by blood closer than would bar marriage in this province, we agree to give notification of any change in the status of our domestic partnership agreement, we share the common necessities of life and are responsible for each others welfare.

We declare that the above statements are true and correct.

______

STAFF MEMBERS SIGNATUREPARTNERS SIGNATURE

DATE SIGNED

DATE OF COHABITATION:

______

(YY-MM-DD)

STAFF MEMBER:

NAME OF STAFF MEMBER(PRINT)UCID NUMBER

______

PARTNER:

NAME OF PARTNER (PRINT)DATE OF BIRTH (YY-MM-DD)

COMPLETE AND RETURN TO HUMAN RESOURCES – CONFIDENTIAL

This information is collected under the authority of the Freedom of Information and Protection of Privacy Act for the purpose of administering the Benefit Plans and will form part of your personnel file. If you have questions about the collection or use of this

information please contact (403) 220-5932.

F:\PENBEN\BENADMIN\WELCOME FORMS\Domestic Partner Declaration .doc

HUMAN RESOURCES GUIDELINES

FOR THE EXTENSION OF BENEFITS TO SAME-SEX PARTNERS

University Benefits

applies consistently to all staff groups

definition of eligible dependent is changed to recognize same-sex partner arrangement

-compares to common-law marriage, i.e. domestic partners

-one-year cohabitation required

-only one domestic partner permitted at a time, e.g. in marriage breakdown, the separated spouse is the legal partner and continues to be eligible as a dependent until the staff member notifies us that the legal spouse is no longer a dependent. One-year cohabitation with current domestic partner is required in cases of serial partnership.

applies to Blue Cross extended health and dental benefits, and optional spousal accidental death and dismemberment insurance (if covered - AUPE not eligible for AD&D)

-will not affect overall premium rates - rates are based on plan utilization experience

-increase individuals rate from single to family

does not apply to University pension plans

-the Income Tax Act does not recognize same-sex spouses

-same-sex spouse not eligible for spousal protection or spousal death benefits if death-in-service

- retirees who do not have a legal spouse can take a joint-life pension with anyone

does not apply to Alberta Health Care - eligibility criteria determined by Alberta Health regulations

Documentation required

Domestic Partner Declaration

-to be completed by staff members who have a common-law partner (whether same sex or opposite) when initial documentation is done at hire or when changing status of dependents

-HR responsibility to have consistent treatment of common-law status, regardless of gender of domestic partner

DOMEPART.WPD

October 4, 1995