In navigating the intricacies of employee benefits within the University of Wisconsin System, the UWS 50 form serves as a crucial affidavit for certifying domestic partnerships, specifically when it comes to enrolling in optional, employee-pay-all benefit programs. This document, formally known as the UWS Affidavit of Domestic Partnership, is designed for those employees who wish to provide their domestic partners with access to benefits like Vision Insurance, Dental Insurance, and Accidental Death & Dismemberment Life Insurance, among others. It's important to note that this affidavit does not extend to the benefits governed by Chapter 40 of Wisconsin Statutes, such as those related to the Wisconsin Retirement System, State Group Health, and Life Insurance, highlighting a distinct pathway for employees whose benefit considerations fall outside of ETF-administered programs. Moreover, the form stipulates specific criteria for the partnership and mandates the responsibility of partners in verifying the authenticity of their shared information. Misrepresentation, as it cautions, could lead to severe repercussions, including loss of benefits and potential legal action. The affidavit underscores a procedural necessity—algorithmically leading the employees through the dome of legalities to secure benefits for their domestic partners, thereby weaving through the state's regulatory nuances and employer mandates with the intent of fostering familial security and wellbeing.
| Question | Answer |
|---|---|
| Form Name | Form Uws 50 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | false, etf, minneapolis domestic partnership, 2010 |
UWS Affidavit of Domestic Partnership
(Not applicable to health insurance or
any
Employee Information (please type or print)
For Employer Use Only
Affidavit Effective Date:
Reviewed By:
Last Name, First Name, Middle |
Date of Birth |
Gender (M/F) |
Social Security Number |
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Domestic Partner Information (please type or print)
Last Name, First Name, Middle |
Date of Birth |
Gender (M/F) |
Social Security Number |
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Address of Residence Shared by Both Domestic Partners (please type or print)
Street Address |
City |
State |
Country |
Zip/Postal Code |
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DO NOT USE THIS AFFIDAVIT IF YOU WANT TO ENROLL YOUR DOMESTIC PARTNER IN STATE GROUP HEALTH INSURANCE, STATE
GROUP LIFE INSURANCE OR ANY WISCONSIN RETIREMENT
Have you submitted an Affidavit of Domestic Partnership
domestic partnership for benefits administered by ETF (e.g. health insurance, retirement…)? |
Yes |
No |
If yes, you do not need to complete this form because you already created a domestic partnership for benefits purposes. See reverse for benefit enrollment information.
Is your domestic partner employed within UW System?
Declaration
Yes
No If yes, see reverse for instructions.
We, the undersigned, declare that we are in a domestic partnership as defined in Wisconsin Statute §40.02(21d). We understand that this affidavit is solely for the purpose of the University of Wisconsin benefit programs that are not administered by the Department of Employee Trust Funds as authorized by Chapter 40, Wis. Stats. We hereby certify that our partnership complies with all of the following criteria:
1.On the date this document is signed, both of us are legally competent and at least 18 years of age;
2.Neither is legally married to or in a domestic partnership with another person;
3.We are not related by blood in any way that would prohibit marriage under Wisconsin law;
4.We consider ourselves to be members of each other’s immediate family;
5.We agree to be responsible for each other’s basic living expenses;
6.We share a common residence.
We acknowledge and agree to the terms stated herein and we understand that any misrepresentation may result in loss of benefits and/or repayment of insurance benefits erroneously paid on my domestic partner’s behalf. We further understand that if the Insurer suffers any loss due to any false statement contained in this Affidavit, it may bring a civil action against either or both of us to recover its losses, including reasonable attorney’s fees. The Insurer retains the right to verify, at any time, any and/or all of the information set forth herein. If the domestic partnership terminates, we agree to notify my payroll/benefits office by either filing a notarized Affidavit of Termination of Domestic Partnership
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We have read and understand this Affidavit of Domestic Partnership, including the |
Notary Signature and Seal |
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information on the back of this form. We understand that Wis. Stat. §943.395 provides |
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criminal penalties for knowingly making false or fraudulent claims, and hereby certify |
State of ______ County of ________________ |
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that, to the best of our knowledge and belief, the information we provided is true and |
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correct. |
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Signed before me by both parties on |
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Employee Signature |
Date |
Day Phone # |
____________________ |
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Date (mm/dd/yyyy) |
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____________________________________ |
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Domestic Partner Signature |
Date |
Day Phone # |
Notary Signature |
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____________________________________ |
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My commission is permanent/expires on |
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General Information
Purpose
This Affidavit certifies a domestic partnership ONLY for the purposes of enrolling a domestic partner in optional
This document does NOT create a domestic partnership for the purpose of benefits authorized by Chapter 40 Wis. Stats. such as Wisconsin Retirement System benefits, State Group Health Insurance, State Group Life Insurance or Wisconsin Deferred Compensation nor does this document create a registered domestic partnership per Chapter 770, Wisconsin Statutes.
Instructions
This affidavit should only be used if you have never created a domestic partnership under Chapter 40 of Wisconsin Statutes by submitting an ETF Affidavit of Domestic Partnership
Submit a complete and notarized affidavit to your payroll/benefits office to establish your domestic partnership. You may email or fax the affidavit to your payroll/benefits office provided the notary seal is clearly visible in the electronic copy; otherwise your affidavit will be rejected. Your payroll/benefits office will confirm that your affidavit has been received and is valid by sending you a letter confirming your domestic partnership effective date.
Submit benefit enrollment applications with the affidavit to enroll your domestic partner and domestic partner’s dependent children in any desired benefits plans. You must submit all benefit enrollment applications within 30 days of the domestic partnership effective date.
If your domestic partner is also a UW System employee, your domestic partner must submit a copy of the letter confirming the UWS domestic partnership to his/her payroll/benefits office.
If you previously established a UW System domestic partnership with a different domestic partner, you may not enroll a new domestic partner in any benefit plans until you terminate the previous domestic partnership by submitting a UW System Affidavit of Termination of Domestic Partnership
Domestic Partnership and Benefit Coverage Effective Date
Provided you have not established a Chapter 40 domestic partnership with ETF, the effective date of your domestic partnership for all
Once a domestic partnership is established with UW System, the coverage effective date for your domestic partner and his/her dependent children will be the first of the month on or following the receipt of any applicable enrollment applications.
Unless you notify your benefit/payroll office that your domestic partner qualifies as a dependent under IRC § 152, all monthly premiums will be taken on a
Information for Employees Who Previously Established a Domestic Partnership
ETF Domestic Partner Affidavit: If you have submitted the ETF Affidavit of Domestic Partnership
UWS Domestic Partner Affidavit: If you established a UWS domestic partnership prior to January 1, 2010 by submitting a UWS Affidavit of Domestic Partnership
Termination of Domestic Partnership
If the domestic partnership terminates, you must notify your payroll/benefits office by filing a notarized Affidavit of Termination of Domestic Partnership