Form Uws 50 PDF Details

The University of Wisconsin System 50 form is a document used to report financial information for the university system. This document is used to track revenue and expenses, as well as assets and liabilities. The University of Wisconsin System 50 form is due each year on September 15th. The form can be submitted online or by mail. Reports are also available to view online. The UW System 50 Form is a requirement for all public colleges in the state of Wisconsin. This document reports on all finances for the University system, from revenue and expenses, to assets and liabilities. The form must be completed annually, by September 15th, and can be filed online or through mail submissions. Financial reports are also available to view online. For more information on the UW System 50 Form visit the official website here: https://www2.uwsa.edu/adminfinance/accountingoffice/forms-and-instructions/uws-50-university-of-wisconsin-systems-financial-report?lid=bf3dd883a3f14d9c8609cbffe7b02331&u

QuestionAnswer
Form NameForm Uws 50
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfalse, etf, minneapolis domestic partnership, 2010

Form Preview Example

UWS Affidavit of Domestic Partnership

(Not applicable to health insurance or

any ETF-administered benefits)

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

 

 

 

 

Domestic Partner Information (please type or print)

Last Name, First Name, Middle

Date of Birth

Gender (M/F)

Social Security Number

 

 

 

 

Address of Residence Shared by Both Domestic Partners (please type or print)

Street Address

City

State

Country

Zip/Postal Code

 

 

 

 

 

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 SYSTEM-RELATED BENEFITS.

Have you submitted an Affidavit of Domestic Partnership (ET-2371) to the Department of Employee Trust Funds (ETF) to establish a

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 (UWS-51) or providing a copy of ETF’s Affidavit of Termination of Domestic Partnership (ET-2372).

 

We have read and understand this Affidavit of Domestic Partnership, including the

Notary Signature and Seal

 

information on the back of this form. We understand that Wis. Stat. §943.395 provides

 

 

criminal penalties for knowingly making false or fraudulent claims, and hereby certify

State of ______ County of ________________

 

that, to the best of our knowledge and belief, the information we provided is true and

 

 

correct.

 

 

Signed before me by both parties on

 

Employee Signature

Date

Day Phone #

____________________

 

 

 

 

 

 

 

 

Date (mm/dd/yyyy)

 

 

 

 

____________________________________

 

Domestic Partner Signature

Date

Day Phone #

Notary Signature

 

 

 

 

____________________________________

 

 

 

 

My commission is permanent/expires on

 

 

 

 

 

UWS-50 (Revised 12/09)

 

-Over-

 

General Information

Purpose

This Affidavit certifies a domestic partnership ONLY for the purposes of enrolling a domestic partner in optional employee-pay-all benefit programs, including, but not limited, to Vision Insurance, Dental Insurance, EPIC Dental and Excess Medical, Individual and Family Life Insurance and Accidental Death & Dismemberment Life Insurance.

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 (ET-2371) to the Department of Employee Trust Funds to establish a domestic partnership for ETF-administered benefits. This affidavit does not apply to employee benefits authorized by Chapter 40 of Wisconsin Statute that are administered by ETF.

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 (UWS-51) to your payroll/benefits office.

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 non-ETF administered benefits will be the date a valid UWS Affidavit of Domestic Partnership (UWS-50) it is received by your payroll/benefits office. If you later submit the ETF Affidavit of Domestic Partnership Affidavit (ET-2371), it will not create a new enrollment period for your domestic partner to enroll as your dependent in any non-ETF administered benefits.

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 post-tax basis.

Information for Employees Who Previously Established a Domestic Partnership

ETF Domestic Partner Affidavit: If you have submitted the ETF Affidavit of Domestic Partnership (ET-2371) to ETF, you have 30 days from the date that your domestic partnership was established by ETF to submit benefit enrollment applications to your payroll/benefits office to add your domestic partner to eligible benefit plans. You must submit a copy of the ETF domestic partnership acknowledgement letter to your payroll/benefits office along with the applications. You should not complete the UWS Affidavit of Domestic Partnership (UWS-50) because you have already created a domestic partnership for benefits purposes.

UWS Domestic Partner Affidavit: If you established a UWS domestic partnership prior to January 1, 2010 by submitting a UWS Affidavit of Domestic Partnership (UWS-50) to enroll your domestic partner in benefits effective prior to January 1, 2010, you do not need to submit the notarized UWS Domestic Partner Affidavit to maintain coverage for your domestic partner.

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 (UWS-51) or providing a copy of ETF’s Affidavit of Termination of Domestic Partnership (ET-2372). The termination of the domestic partnership will be effective on the date the payroll/benefits office receives the notarized Affidavit of Termination of Domestic Partnership or, if earlier, on a date established to the employer’s satisfaction that the domestic partnership certified in this affidavit no longer meets the definition of a domestic partnership. An Affidavit of Termination of Domestic Partnership must be filed before a new domestic partnership can be established.

UWS-50 (REVISED 12/09)