Affidavit of Domestic Partnership – Human Resources

Employee's Name *

First Last

Domestic Partner's Name *

First Last

Domestic Partner's Email *

Enter Email Confirm Email

Certification *

I certify that the above named is my Domestic Partner.

I understand that, subject to the eligibility provisions of the plans, I have the opportunity to cover my Domestic Partner under my benefit plans under the same terms and with the same privileges and restrictions that apply to other eligible dependents for these plans to the extent permissible under federal and state law.

We are Domestic Partners in accordance with the following criteria: *

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we are each other’s sole domestic partner and intend to remain so indefinitely, and
we are each not married and are each eighteen (18) years of age or older and mentally competent to consent to contract, and
we are not related by blood closer than would prohibit marriage in the state in which we legally reside, and
we share the same regular and permanent residence, have done so for at least the previous six months, intend to do so indefinitely, and
we are jointly responsible for each other’s common welfare and financial obligations.

Required Documentation *

We understand that in order to declare responsibility for our common welfare and financial obligations that we must submit documentation to Human Resources of three (3) of the following:

a. evidence of joint mortgage or lease
b. evidence of designation of Domestic Partner as beneficiary for life insurance and
retirement contract
c. evidence of designation of Domestic Partner as primary beneficiary in the
employee’s will
d. evidence of durable property and health care powers of attorney
e. evidence of joint ownership of motor vehicle, joint checking account or joint
credit account.

Tax Regulations *

We understand

We understand that under current tax regulations, Kalamazoo College may be required by the IRS to report as taxable income, the premium value related to covering my domestic partner under the benefits plan. I acknowledge and understand that the College has advised me to consult with an attorney and tax advisor regarding the legal and tax consequences of signing this certification. I further agree to notify the College immediately of any change in this tax status.

Change in domestic partnership *

We understand and agree.

A. I understand that this affidavit shall be terminated upon the death of my domestic partner or by a change of my circumstance attested to in this affidavit.

I agree to notify the Human Resources Department if there is any change of circumstances attested to in this affidavit within thirty (30) days of change by filing a Statement of Termination of Domestic Partnership.

B. After such termination, I understand that another Affidavit of Domestic Partnership cannot be filed until one year after a Statement of Termination of Domestic Partnership has been filed with Human Resources.

Additional Acknowledgements *

We acknowledge.

We understand that this information will be held confidential and will be subject to disclosure only upon our express written authorization or if otherwise required by law.

We understand that a civil action may be brought against us for any losses, including reasonable attorney’s fees, because of a false statement contained in this Affidavit of Domestic Partnership.

We also certify under penalty of perjury, under laws of the state of Michigan, that the foregoing is true and correct.

I, the undersigned Kalamazoo College Employee, understand that willful falsification of information on this affidavit may lead to disciplinary action, up to and including discharge from employment.

Signature of Employee *

Signature of Domestic Partner