AFFIDAVIT OF DOMESTIC PARTNERSHIP Valencia College Employee Information Name:
Employee ID #:
Address:(street, city, state, zip)
Phone number:
Gender: [m/f] Date of birth:
Status Your request to enroll a domestic partner is based on criteria establishing that a domestic partnership exists. In order to properly evaluate your request and the eligibility of the domestic partner, you must complete the following information: Domestic partner’s name: Date of birth: Gender: [m/f] Address (street, city, state, zip) On what date was the domestic partnership established? If so, on what date did you begin sharing a residence?
Do you share the same residence? [y/n]
Are you each other’s sole domestic partner, and intend to remain so indefinitely? [y/n]
AFFIDAVIT We understand that in order for Domestic Partner coverage to become effective, an Affidavit of Domestic Partnership must be submitted and approved, and we must satisfy the following requirements. We hereby swear or affirm that we satisfy the following requirements: 1. 2. 3. 4.
We are each other’s sole domestic partner and intend to remain so indefinitely. We are at least eighteen years of age and mentally competent to consent to this declaration. We have shared the same residence for at least twelve consecutive months, and continue to do so Neither of us is married (as defined by Florida Law) to anyone else or legally separated from anyone else. 5. We are not related by blood to a degree of closeness that would prohibit legal marriage in Florida if we were of different sexes. (For example, siblings or first cousins.) 6. We are jointly responsible for each other’s financial welfare and basic living expenses as evidenced by at least two of the following: [check all that apply]: (Note: you must submit two “different” types of evidence and at least one of these documents of proof must reflect joint responsibility for Twelve months prior to submission of this Affidavit.) — — — — — — — —
Common ownership of real property or a common leasehold interest in property. Joint checking account. Joint credit cards. Proof of Shared Living Expenses. Designation of one another as primary beneficiary for life insurance or retirement benefits, or primary beneficiary designation under partner’s will. Joint ownership of a motor vehicle. Designation of partner under power of attorney. Declaration of Partner as health care surrogate.
________________________________________ Employee
____________________________________________ Domesti c partner
Sworn To & Subscribed Before Me
Sworn To & Subscribed before me
This ______Day Of _____ 20__
This ______Day of ____________ 20____
By __________________________________Who is personally
by _______________________________ who is personally
Known to Me Or who Has Proved ____________________
known to me or who has provided _________________
As Identification.
As identification.
________________________________________ Notary Public
____________________________________________ Notary Public
Eligibility of Domestic Partner’s Dependent Child(ren) We understand the child(ren) are eligible for coverage under the Benefits so long as they otherwise satisfy the Plan’s Policies' definition of an eligible dependent child and you complete an enrollment form on their behalf. Full time Full name of child(ren) Name of parent DOB M/F SSN student? [y/n]
ACKNOWLEDGEMENTS 1. The above listed child(ren) reside with us and the Domestic Partner is responsible for the child(ren)’s well being; or the Domestic Partner is required to provide coverage for the child(ren) by court order; or 2. The child(ren) qualifies as the Domestic Partner's dependentfor tax purposes under the federal guidelines. (Attach a copy of the federal income tax return); and 3. The child(ren) continues to meet the eligibility requirements as outlined in the Plan’s definition of a Dependent.
ACKNOWLEDGEMENTS 1. We understand Domestic Partners (and their eligible dependents) are subject to the same rules governing all other dependents who are covered by or apply for coverage under the benefits/policies, including but not limited to those rules relating to enrollment periods. Further we understand we must complete the enrollment process for eligible benefits to be effective. 2. We understand that termination of coverage issued to the Domestic Partner as a result of completion and approval of this Affidavit will be effective on the date the Domestic Partnership ends, providing coverage did not terminate earlier under other Plan provisions. We further understand the Domestic Partner and any child(ren) of the Domestic Partner do not have rights to COBRA or continuation of coverage under existing federal law, however, certain conversion privileges may apply. 3. If health care, dental, vision, and/or supplemental life coverage is requested, I will provide to Valencia’s Benefits section documents establishing the existence of my Domestic Partner Relationship and complete the enrollment process either online or in writing. 4. We understand we have an obligation to submit to Valencia an Affidavit of Termination of Domestic Partnership within 30 days of when Domestic Partnership eligibility requirements are no longer met or within 30 days of the death of my Domestic Partner. Coverage of your Domestic Partner will terminate on the date of death of the Domestic Partner or on the last day of the first month that the Domestic Partner and/or Domestic Partner’s eligible dependent child(ren) fails to continue to meet all the applicable Domestic Partnership eligibility requirements. 5. We understand that Valencia may make a claim against one or both of us for any losses (including attorneys’ fees and costs) due to any false statement contained in this Affidavit, or for failure to notify the College of a change in our Domestic Partnership status. 6. We understand this Affidavit may have other legal ramifications, and that we were advised to seek competent legal advice regarding these matters before signing this Affidavit. Employee signature Date
Domestic partner’s signature
Date