Partners Task Force for Gay & Lesbian Couples
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Sample Domestic Partnership Affidavit I
A simple form
© 2001, Demian

The following affidavit provides a simple definition of “domestic partner” for benefits purposes. It defines as little as possible, so that a couple would not compromise other relationship documents that define their financial or living-together agreements.

Occasionally an employer will ask an employee to obtain a domestic partnership “registration” as a means of gaining benefits. This can be challenging because most registrations are only available if you are residing in a county, city, or in one of the few states that offers such status. And while you may be able to obtain a registration — usually costing about $35 — they offer few benefits of their own, and have no legal effect outside their own jurisdiction.

There is no universal template for registrations or benefits affidavits, as there is with legal marriage. Whenever a government or private employer chooses to create a definition of family for benefits purposes — which becomes embodied in an affidavit — they often use different definitions. This sort of chaos is yet another result of denying legal marriage to same-sex couples.

Just as most employers never ask to see a marriage license, we think all that should be required is for a couple to declare themselves a family. It really is not the domain of business to make such definitions.

Declaration of Domestic Partnership

We certify and declare that we are in a domestic partner relationship, and that we are each other’s sole domestic partner. We are engaged in a committed relationship, and we are:

  1. At least 18, and mentally competent to consent to a civil contract; and
  2. Not acting under force or duress; and
  3. Not married to, or legally separated from, any other person, and
  4. Not in another domestic partnership.
We affirm, under penalty of perjury, that the statements in this Declaration are true and correct.

Employee: _______________________________ Date: ________

Printed name: ____________________________ Birth date: ________

Address: ____________________________________________

Domestic partner: _______________________________ Date: ________

Printed name: ____________________________ Birth date: ________

Address: ____________________________________________

Declaration of Termination of Domestic Partnership

I certify and declare that I am no longer in a domestic partner relationship.

I affirm, under penalty of perjury, that the above statement is true and correct.

Employee: ________________________________ Date: ________

Printed name: _________________________

© 2001, Demian

Also see:
Sample Domestic Partnership Affidavit II — a complex form
Anatomy of a Domestic Partnership Affidavit

Return to: Domestic Partnership Benefits

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