AFFIDAVIT OF DOMESTIC PARTNERSHIP

County of [COUNTY]
State of [STATE]

1. THE PARTNERS. On [MM/DD/YYYY], this Domestic Partnership Affidavit (“Affidavit”) declares the following individuals to be considered in a domestic partnership:

Partner 1: [PARTNER 1 NAME]
Partner 2: [PARTNER 2 NAME]
Address: [PARTNERS’ ADDRESS OF RESIDENCE]

Partner 1 and Partner 2 shall be referred to collectively as the “Couple” and declare to be domestic partners in accordance with the following criteria:

2. DECLARATION. We, the Couple, affirm that this relationship began on or about [MM/DD/YYYY], and acknowledge the following to be true and correct:

a) We are both at least eighteen (18) years of age and mentally competent to consent.
b) We are not related by blood to a degree of closeness that would prohibit legal marriage in the State in which we legally reside.
c) We are each other’s sole domestic partner, and we intend to remain so indefinitely.
d) Neither of us is legally married or legally separated from anyone else, and neither of us has had another domestic partner within the past six (6) months.
e) We cohabit and reside together in the same residence and intend to do so indefinitely. We have resided in the same household for at least six (6) months or the legally required period.
f) We are not in this relationship solely for the purpose of obtaining benefits coverage.
g) We are engaged in a committed relationship of mutual caring and support and are jointly responsible for our common welfare and living expenses. Our interdependence is demonstrated by having any of the following:

i) Common ownership of real property (joint deed or mortgage agreement) or a common leasehold interest in property
ii) Common ownership of a motor vehicle
iii) Drivers’ licenses both listing a common address
iv) Proof of joint bank accounts or credit accounts
v) Proof of designation as the primary beneficiary for life insurance or retirement benefits, or primary beneficiary designation under a partner’s will
vi) Assignment of a durable financial power of attorney or health care power of attorney (advance directive)

3. CHANGE IN DOMESTIC PARTNERSHIP. We, the Couple, agree to notify all parties offering benefits due to our domestic partnership status within thirty (30) days of any change or termination. In addition, if a domestic partnership is terminated, another may not be created for another six (6) months.

4. ACKNOWLEDGMENTS. We, the Couple, have provided the information located in this Affidavit for the sole purpose of determining our eligibility for domestic partner benefits within the state of [STATE]. We further understand that any false or misleading statements made in order to receive benefits for which we do not qualify may be subject to disciplinary action.

Partner 1 Signature: ______________________________ Date: _______________
Print Name: [PARTNER 1 NAME]

Partner 2 Signature: ______________________________ Date: _______________
Print Name: [PARTNER 2 NAME]

NOTARY ACKNOWLEDGMENT

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

State of [STATE]
County of [COUNTY]

The foregoing instrument was acknowledged before me, [NOTARY PUBLIC NAME], on [MM/DD/YYYY], by the undersigned, [AFFIANT NAME], who is personally known to me or satisfactorily proven to me to be the person whose name is subscribed to the within instrument.

WITNESS my hand and official seal.

Signature: ________________________

(Seal)