Domestic Partners Statement of Relationship

[Company Name]

_______________________________        __________________________
Employee name (print)                                   Domestic partner name (print)

We certify the following:

• We are each other's sole domestic partner.
• Neither of us is legally married to anyone.
• Each of us is at least eighteen (18) years old and mentally competent to consent to this contract.
• We are not related by blood to a degree of closeness that would prohibit legal marriage in this state.
• We are jointly responsible for each other's common welfare and shared financial obligations which may be demonstrated by the existence of three of the following. We have circled below the types of documentation that we can provide if requested.
  
  

• We agree to notify Human Resources if there is any change in our status as domestic partners as certified in this statement. We will notify Human Resources within thirty (30) days of such change by filing a statement of Termination of Domestic Partnership, which will make the domestic partner no longer eligible for [Company Name]-sponsored benefits. The statement of termination shall affirm that the domestic partnership status is terminated as of its date of execution and that a copy of the statement of termination has been provided to the other partner by the party authorizing such action.
• We understand that any false or misleading statements made in order to receive benefits for which we do not qualify may subject the individual employed by [Company Name] to disciplinary action, loss of benefits and an obligation to reimburse [Company Name] for any costs involved in providing benefits coverage.
• We have provided the information in this statement for the sole purpose of determining our eligibility for [Company Name] provided domestic partner benefits. We understand that this information will be held confidential insofar as the law allows and will otherwise be subject to disclosure only upon our expressed written authorization.
• We acknowledge [Company Name]'s advice that we consult with a legal advisor before signing this document.

___________________________________                   ___________________
Employee Signature                                                       Date

___________________________________                   ____________________
Domestic Partner Signature                                           Date

Subscribed and sworn to before me this ___ day of ___________, 20__.

__________________________________________ Notary Public