I. Declaration of Marriage

We, _____________________________, employee, and _________________________, spouse, each certify and declare that we have been married since ______________ (date). A copy of our marriage license is attached to this Declaration.

II. Declaration of Domestic Partner Status

We, _____________________________, employee, and _________________________, domestic partner, each certify and declare that we are each other’s sole domestic partners as set out below.

1. We are both at least eighteen (18) years old and mentally competent to consent to a civil contract; and
2. We are not acting under force or duress; and
3. Neither of us is married to or legally separated from any other person and neither of us is engaged in another domestic partnership; and
4. We are not related by blood or marriage to a degree of closeness that would prohibit legal marriage in the state in which we reside; and
5. We are engaged in a committed relationship of mutual caring and support and are jointly responsible for our common welfare; and either:
   1. We are jointly responsible for our assets and debts as provided by applicable law; or
   2. We have executed a written agreement or civil contract, which defines our domestic partnership and our liabilities with respect to our assets and debts.

1. The employee has an obligation to ensure that the Human Resources Department of [company name] receives a notice of termination of marriage, or written Declaration of Termination of Domestic Partnership, if there is any change in the marital or domestic partnership status that makes this Declaration invalid or erroneous. Notice shall be provided to the Department within thirty-one (31) days of such change.
2. The employee understands that termination of benefit coverage obtained as a result of this Declaration will be effective on the last day of the month during which the domestic partnership ends or at such time as coverage terminates in accordance with the terms and conditions of applicable policies. Receipt by [company name] of a Declaration of Termination of Domestic Partnership or notice of termination of marriage from either partner shall be deemed conclusive evidence of the termination of the domestic partnership status for purposes of this benefit. In the event that more than one such Declaration of Termination of Domestic Partnership or notice of termination of marriage is provided with conflicting dates of termination of the marriage or domestic partnership, [company name] shall rely on the document with the earlier date.

1. We understand that a civil action may be brought against one or both of us for any losses (including attorney’s fees and costs) due to any false statement contained in this Declaration or for failure to notify [company name] of changed circumstances as required in Section III, above. The undersigned employee further understands that falsification of information in this Declaration or failure to notify [company name] of changed circumstances pursuant to Section III, above, may lead to disciplinary action, including discharge from employment.
2. We have provided information in this Declaration for use by [company name] for the sole purpose of determining our eligibility for certain health insurance benefits. We understand and agree that [company name] is not legally required to extend such benefits to spouses or domestic partners and that [company name] may change or terminate these benefits in its discretion without consent of any employee or group of employees.
3. We understand that the information provided in this Declaration will be treated as confidential by [company name] but will be subject to disclosure:
   1. upon the express written authorization of the undersigned employees or
   2. if otherwise required by law.
4. We understand that this Declaration may have legal implication relating, for example, to our ownership of property or to taxability of benefits provided. We understand that before signing this Declaration we should seek competent legal and tax advice concerning such matters. We acknowledge that [company name] has provided us with no advice in this regard.

Employee: _______________________________ Date: ________

Printed name: ____________________________ Birth date: ________

Address: ____________________________________________

Spouse/domestic partner: _______________________________ Date: ________

Printed name: ____________________________ Birth date: ________

Address: ____________________________________________

I, ___________________________ (employee), and/or I, ______________________________ (former spouse/domestic partner), certify and declare that ______________________________ (former spouse/domestic partner) and I are no longer married or domestic partners as of _________________ (date). I/We understand that coverage for this former spouse/domestic partner will end on the last day of the month during which the marriage or domestic partnership is terminated.

I make and file this Declaration of Termination in order to cancel the Declaration of Marriage or Domestic Partnership filed by me on ______________ (date) because we no longer meet all of the requirements of marriage or domestic partnership under the [company name] health insurance coverage arrangements set forth in Declaration of Marriage or Domestic Partnership.

I, the employee of [company name], understand that another Declaration of Domestic Partnership cannot be filed until [wait period before divorced parties may remarry in this state] days after the date the relationship ended as set forth above.

I affirm, under penalty of perjury, that the above statements are true and correct.

Employee: _______________________________ Date: ________

Printed name: _________________________

Former spouse/domestic partner: _______________________________ Date: ________

Printed name: _________________________