Confidential

Indiana University
AFFIDAVIT OF DOMESTIC PARTNERSHIP

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Employee Information

Name:

Last   First   Middle

Address:

Street

 

City      Zip

 

Country

Social Security #: - -     Date of Birth: / /    Gender: Male Female

Domestic Partner Information

Name:

Last   First   Middle

Address:

Street

 

City      Zip

Social Security #: - -           Date of Birth: / /    Gender: Male Female

Partnership began on:

Domestic Partner Dependent Child Information

(List only the domestic partner’s unmarried biological or adopted 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

RC*

Married

Full-time Student

DS
DD

Y
N

Y
N

DS
DD

Y
N

Y
N

*RC (Relationship Code): DS = biological or adopted son of domestic partner DD = biological or adopted daughter of domestic partner

 

DECLARATION

We, the undersigned, declare that:

  1. We are at least 18 years of age and competent to enter into a contract.
  2. We are the same sex and, therefore, prevented from marrying in Indiana.
  3. We are not married and are not the domestic partner of any other person.
  4. We are not related by blood closer than would bar marriage in the state of Indiana.
  5. We have been living together as a couple and share a residence and have done so for more than six (6) consecutive months prior to this declaration.
  6. At least six months have passed since the termination of any previous same-sex domestic partnership.
  7. We attest that our relationship is an exclusive mutual commitment that is the functional equivalent of a marriage; that is,
    • we are jointly responsible for each other for the necessities of life including each other’s debts; and
    • we intend to remain in the relationship indefinitely; and
    • we would enter into a legal marriage if the opportunity were available; and
    • we have agreed that in the event of dissolution of our domestic-partner relationship, we will make an equitable division of any earnings acquired during our domestic partnership and of property acquired with those earnings; that is, a division of property similar to that legally required of a married couple in the event of a divorce.
  8. In lieu of the marriage certificate that the University requires to cover an employee’s spouse, we are submitting the following supporting documentation to verify our interdependent financial relationship:
    1. Joint ownership of residence (home, condo, mobile home) or a lease for a residence identifying both partners as tenants, and
    2. Two of the following: joint ownership of a motor vehicle; joint credit account; joint checking account; or other evidence of joint ownership of a major asset or joint liability of debt.

ACKNOWLEDGEMENTS

  1. We have read and understand the eligibility requirements, employee responsibilities, and tax information described in the Domestic Partner Benefits Program Eligibility Information sheet.
  2. Indiana University has advised us to consult with an attorney regarding the legal consequences of signing this declaration; for example, whether this document can be used by creditors to hold one partner responsible for the debts of the other or whether a partner may use this document as entitlement to division of property acquired during the partnership.
  3. We waive, release, and indemnify the university from all claims and causes of action that may arise as a result of the university affording benefits to, or certifying domestic partnerships.
  4. Indiana University’s cost for providing domestic-partner benefits and the employee’s payroll contribution will generally be taxable income to the employee unless the domestic partner and partner’s dependent children are qualified tax dependents of the employee.
  5. The employee is responsible for notifying Indiana University by submitting a Termination of a Domestic Partnership form within 60 days of the date that we no longer meet the eligibility requirements for domestic-partner benefits. We understand that eligibility for domestic-partner benefits ends on the day that we no longer meet the eligibility requirements.
  6. This affidavit is requested for the purpose of Indiana University making a determination of our eligibility for domestic-partner benefits provided by Indiana University; that this information will be held confidentially, but will be disclosed as needed to arrange benefits with applicable third party administrators or as required by law or a court; and that the university may be required to make the records of this domestic partnership available to the public under the Freedom of Information Act.
  7. We understand that the university may change benefit coverage and eligibility at any time.
  8. We understand that the University will require annual re-certification of eligibility for domestic partnership.

CERTIFICATION

We certify that the forgoing information is true and correct and understand that a false declaration of a domestic partnership or failure to file a timely notice of Termination of a Domestic Partnership with University Human Resource Services may result in disciplinary action up to and including termination of employment at Indiana University. We agree that in the event of a false declaration, or the failure to file a Termination of a Domestic Partnership form with the university, Indiana University may recover damages from either or both of us for all costs and expenses incurred by the university as a result of that false declaration, 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: __________________

 

For University Use Only

 

Affidavit received and approved by:________________________________ on___________________________

 

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