Declaration of Domestic Partnership

AFFIDAVIT

Employee Name: Employee Birth Date:
Employee Social Security Number: Employee Gender:
Partner's Name: Partner's Birth Date:
Partner's Social Security Number: Partner's Gender:

Employee and Partner's Address:

 


Group Number: ______________________________

Partner's Dependent Children
Social Security Number
Birth Date
Do you and your partner provide the majority of support for this child?
Does this child reside in your household?
Do you or your partner claim this child for income tax purposes?
           
           
           
           
           


We the undersigned, declare that we are domestic partners, as established by the following criteria:
1. We are the same gender and for this reason are unable to marry each other under the laws of the state in which we reside;
2. We are at least 18 years of age and have the capacity to enter into a contract;
3. We are not related by blood closer than permitted under the marriage laws in our state of residence;
4. We share a residence;
5. We are jointly responsible to each other for the necessities of life. If asked, we could produce documentation of at least three of the following items as evidence of our joint responsibility:


______
 Proof of shared residence as documented in joint mortgage or joint tenancy on a residential lease, driver's license, or non-driver identification
______
 Joint bank account
______
 Joint liabilities (e.g., credit cards or car loans)
______
 Joint ownership of significant property (e.g., cars, land, etc.)
______
 Naming each other as primary beneficiary in wills or life insurance policies
______
 Written agreements or contracts regarding our relationship showing mutual support obligations or joint ownership of assets acquired during the relationship


6.

We are not married and neither of us has any other domestic partners;
7. We are engaged in a long-term committed relationship and intend to remain together indefinitely;
8. The children identified above qualify as dependents under IRS regulations for our household.


Declaration of Domestic Partnership, page 2

The employee agrees to be responsible for paying all health premiums, where applicable, and authorize the employer to deduct the required contributions as payroll deductions. In addition, the employee understands that the domestic partner named below and his/her children will not be recognized as qualified dependents for tax purposes. Therefore, the employee agrees to have the employer calculate the imputed income on the value of the insurance coverage being provided to the domestic partner and partners' children named in this affidavit.

The employee must notify Blue Cross and Blue Shield of Minnesota within thirty (30) days of the termination of the domestic partnership under the above criteria by filing a Notice of Termination of Domestic Partnership with the employer.

I agree that in the event of a false Declaration of Domestic Partnership, Blue Cross and Blue Shield of Minnesota may recover damages for all losses and reasonable attorneys' fees incurred to recover such damages.

We acknowledge and understand that the employer advises us to consult with an attorney regarding the legal consequences of signing this declaration.

We provide this information for the sole use of the employer and Blue Cross and Blue Shield of Minnesota and for the sole use of determining our eligibility for domestic partner benefits. If we do not provide this information, we understand we will not be eligible for domestic partner benefits.

We understand that this affidavit includes confidential information and will only be disclosed to persons who require this information for the purpose of administering domestic partner benefits.

_________________________________ _________________________________
Signature of Employee Signature of Domestic Partner
_________________________________ _________________________________
Date Date
   
   

Subscribed and sworn to before me this

___________ (day) of ____________________ (month), (year) ______________.

________________________________________________________________
Notary Public

 

To be completed by Human Resources -- Benefits:

Eligibility

__ Approved / ___ Denied

 Signature Date

Blue Cross and Blue Shield of Minnesota
X13001 (9/98)