Maryland Domestic Partnership Form PDF Details

In Maryland, the process of recognizing a domestic partnership and extending benefits to a domestic partner and their dependents involves a detailed legal procedure, as outlined in the Maryland Domestic Partnership form. This form, crucial for domestic partners seeking to avail themselves of shared benefits, requires comprehensive information and affirmations from both parties involved. Central to this form is the Affidavit for Domestic Partnership and Domestic Partner’s Dependents, which mandates that both partners declare their commitment to a mutually supportive relationship that is intended to be indefinite. Partners must confirm that they are over the age of 18, not related by blood or marriage within a prohibited degree, not currently married or in a domestic partnership with someone else, and have lived together in a relationship of mutual interdependence for at least 12 consecutive months. Documentary evidence, such as joint ownership or lease documents, shared financial accounts, and mutual designations in legal documents like wills or health care directives, is required to demonstrate financial interdependence and a common primary residence. Additionally, the form inquires about the eligibility of the domestic partner for tax-favored treatment based on dependency criteria, further emphasizing the form’s role in aligning domestic partnerships with recognized legal and financial frameworks. This meticulously designed affidavit ensures that domestic partners and their dependents can achieve a semblance of the legal recognition and benefits traditionally reserved for married couples, upon successful submission and approval of the required documentation.

QuestionAnswer
Form NameMaryland Domestic Partnership Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesmaryland domestic partnership application, baltimore county domestic partnership, maryland affidavit partnership, maryland affidavit partnership domestic

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Affidavit for Domestic Partnership and Domestic Partner’s Dependents

This Affidavit must be completed if you are adding coverage for a Domestic Partner or Dependent Child of a Domestic Partner

 

Domestic Partnership:

I, _________________________________ and

________________________________________,

(Employee/Retiree)

(Domestic Partner)

certify that we are Domestic Partners (as defined in the benefits guide) and that we:

(1)Are each at least 18 years old;

(2)Are not related to each other by blood or marriage within four degrees of consanguinity under civil law rule;

(3)Are not married, in a civil union, or in a domestic partnership with another individual;

(4)Have been in a committed relationship of mutual interdependence for at least 12 consecutive months in which each individual contributes to some extent to the other individual’s maintenance and support with the intention of remaining in the relationship indefinitely;

Financial Interdependence is established by providing one of following dated documents:

(a)Joint ownership or lease of a motor vehicle

(b)Joint lease, mortgage or deed of your primary residence

(c)Joint checking, savings, investment, or credit account

(d)Designation as the primary beneficiary for life insurance, retirement benefits or the domestic partner’s will

(e)Mutual assignments of valid durable powers of attorney under Estates and Trusts Article, §13-601, Annotated Code of Maryland

(f)Mutual valid written advanced directives under Health-General Article, §5-601 et seq., Annotated Code of Maryland, approving the domestic partner as health care agent.

(5)Share our common primary residence.

Common Primary Residence is established by providing one of the following documents:

(a)Joint lease, mortgage or deed of your primary residence

(b)Copies of individuals’ driver’s license, State-issued identification card or voter’s registration card listing common primary address

(c)Utility or other household bill with both the name of the insured and the domestic partner appearing.

Tax Affidavit for Domestic Partner:

In some cases, your Domestic Partner may qualify as an eligible tax dependent. If he/she meets all three criteria below, the coverage attributable to your domestic partner may be eligible for tax-favored treatment. Please initial each description that applies to your Domestic Partner only if all three apply AND include a copy of your most recent income tax filing (with salary information blacked out).

Initials

Tax Dependent Criteria:

 

The Dependent is a person who is not my lawful spouse who lives with me and is a member of my household

 

for the entire year.

 

I provide over half of the Dependent’s support for the calendar year(s) in which coverage is provided.

 

The Dependent is not my or anyone else’s qualifying child for the tax year(s) in which coverage is provided.

We solemnly affirm under the penalties of perjury under applicable state laws, that the foregoing is true and accurate. We understand that willful falsification of information contained in this Affidavit can result in referral of the matter for investigation and prosecution, the termination of enrollment and coverage of the domestic partner, and the termination of coverage for the employee/retiree. We understand that a civil action may be brought against us for any losses, including reasonable attorney fees, because of a false statement contained in this affidavit. In addition, where permissible, employment related action may be taken against an active employee.

We agree to promptly notify the Department of Budget and Management, Employee Benefits Division upon any changes or circumstances attested to in this affidavit. We understand that we may not file another affidavit until at least one (1) year after termination of this domestic partnership.

_________________________________________ __________________________

_________________________

Signature of Employee/Retiree

Social Security Number

Date

_____________________________________ ________________________

_________________________

Signature of Domestic Partner

Social Security Number

Date

Dependent Tax Affidavit for Domestic Partner’s Dependents:

Name of Employee/Retiree: ________________________________ Social Security Number: __________________________

Name of Domestic Partner’s Dependent: _____________________________________________________________________

Dependent’s Date of Birth: ______________________Social Security Number: ______________________________________

Part A: Dependent Relationship, Marital Status, and Age/Capability Requirements

A. Initial the box for the correct dependent relationship for your domestic partner’s dependent listed above. If none apply, this person is NOT eligible to be added to your health benefits coverage.

Initials

 

Dependent Relationship

Required Documentation

 

Biological Child of Domestic Partner

- Copy of Child’s Official State Birth Certificate

 

 

 

 

Adopted Child or child placed with domestic partner for adoption

- Copy of Adoption papers indicating child’s date of birth

 

by the Domestic Partner

- For pending adoptions – see Benefits Guide

 

 

 

 

Step-Child of Domestic Partner

- Copy of Child’s Official State Birth Certificate

 

 

 

- Copy of domestic partner’s Official State Marriage Certificate from

 

 

 

previous marriage

 

Grandchild of Domestic Partner

- Copy of Child’s Official State Birth Certificate

 

 

 

- Copy of Child’s Parent’s Official State Birth Certificate (to show

 

 

 

relationship to domestic partner)

 

Legal Ward of Domestic Partner (permanently resides with my

- Copy of Child’s Official State Birth Certificate

 

domestic partner and my domestic partner is his/her testamentary

- Proof of Residency (Valid Driver’s License, or State-issued

 

or court appointed

guardian for a non-temporary guardianship of

Identification Card, school records or day care records certifying

 

not less than 12 months.)

dependent’s address, Tax Documents listing child’s name certifying

 

 

 

address.)

 

 

 

- Copy of Legal Ward/Testamentary Court

 

 

 

Document, signed by a Judge.

 

Other Child Relative (includes step-grandchildren) of Domestic

- Copy of Child’s Official State Birth Certificate

 

Partner - dependent is related to my domestic partner by blood,

- Proof of Residency (Valid Driver’s License, or State-issued

 

permanently resides with my domestic partner, and my domestic

Identification Card, school records or day care records certifying

 

partner provides his/her sole support.

dependent’s address, Tax Documents listing child’s name certifying

 

 

 

address.)

 

 

 

- Signature of Sole Support Affirmation (see below)

B. Initial the box below, if the Dependent is NOT married. If this person is married, he/she is NOT eligible for State employee/retiree health benefits coverage.

The Dependent is NOT married

C. Initial the box by the statement that describes the Dependent. If neither statement accurately describes this Dependent, this person is not eligible for State employee/retiree health benefits coverage.

The Dependent is under the age of 25.

The Dependent is any age and is incapable of self-support because of a mental or physical incapability incurred before reaching age 25 and is chiefly dependent on me and/or my domestic partner for support.

Sole Support Affirmation for Other Child Relative Dependent ONLY:

I certify by my signature below that the dependent child listed on this form is supported solely by me and/or my domestic partner.

___________________________________________

_____________________

Domestic Partner’s Signature

Date

Part B: Tax Criteria:

In some cases, the dependent of your Domestic Partner may qualify as your eligible tax dependent. If he/she meets all four criteria for the Qualifying Child Test or all three criteria for the Qualifying Relative Test on the following page the coverage attributable to your domestic partner’s dependent may be eligible for tax-favored treatment. If you cannot initial all four Qualifying Child or all three Qualifying Relative criteria, this person is NOT an eligible tax dependent and the portion of your coverage attributable to this dependent is not eligible for tax-favored status.

Initials

Qualifying Child Test Criteria – must meet all four criteria

 

The child is my biological child or adopted child (or placed for adoption by me), my legal ward or child placed with me

 

under court order (not temporary for less then 12 months), sibling, or descendent of my child or sibling (i.e. grandchild,

 

niece, nephew, etc); and

The child lives with me for more than half of the year (more than six months) or is my biological or adopted child and meets the following residence exceptions:

-The child received over half of the child’s support during the calendar year from the child’s parents, who (1) are divorced or legally separated under a decree of divorce or separate maintenance, or (2) are separated under a written separation agreement, or (3) live apart at all times during the last six months of the calendar year; and

-The child is in the custody of one or both of the child’s parents for more than half of the calendar year; and

-

The Child (1) has not attained age 19 as of the close of the calendar year(s) in which coverage is provided, or (2) is a full- time student for at least five months of the calendar year who has not attained age 24 as of the end of the calendar year(s) in which coverage is provided, or (3) is permanently and totally disabled; and

 

The child has not provided more than half of the child’s own support for the calendar year(s) in which coverage is provided.

 

 

 

 

-OR-

 

 

Initials

Qualifying Relative Test Criteria – must meet all three criteria

 

The Dependent has a specified relationship to me: my biological child, my adopted child (or placed for adoption by me),

 

my step-child, my grandchild, my niece, my nephew, my sibling, or a person who is not my lawful spouse who lives with

 

me and is a member of my household for the entire year (this includes a legal ward); and

 

 

 

I provide over half of the Dependent's support for the calendar year(s) in which coverage is provided; and

 

 

 

The Dependent is not my or anyone else's qualifying child for the tax year(s) in which coverage is provided. If this child meets

 

criteria for the Qualifying Child Test, this statement is not true.

We solemnly affirm under the penalties of perjury under applicable state laws, that the foregoing is true and accurate.

We understand that willful falsification of information contained in this Affidavit will result in our termination of enrollment. We understand that a civil action may be brought against us for any losses, including reasonable attorney fees, because of a false statement contained in this affidavit.

_________________________________________

_________________________

Signature of Employee/Retiree

Date

_________________________________________

_________________________

Signature of Domestic Partner

Date

Rev 9/1/09

 

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This PDF form requires particular data to be entered, therefore ensure that you take some time to enter precisely what is requested:

1. Complete your maryland domestic partnership affidavit with a selection of essential blanks. Collect all of the required information and ensure absolutely nothing is left out!

baltimore county domestic partnership writing process explained (part 1)

2. The subsequent stage is to complete these particular fields: Tax Affidavit for Domestic Partner, Tax Dependent Criteria, The Dependent is a person who is, We solemnly affirm under the, Signature of EmployeeRetiree, Social Security Number, Social Security Number, and Date Date.

Step # 2 in filling in baltimore county domestic partnership

Be extremely mindful while completing We solemnly affirm under the and Tax Dependent Criteria, because this is where a lot of people make errors.

3. Completing Name of EmployeeRetiree Social, Name of Domestic Partners, Dependents Date of Birth Social, Part A Dependent Relationship, A Initial the box for the correct, Dependent Relationship, Required Documentation Copy of, Biological Child of Domestic, Adopted Child or child placed with, Copy of Adoption papers, StepChild of Domestic Partner, Grandchild of Domestic Partner, Legal Ward of Domestic Partner, Other Child Relative includes, and Copy of Childs Official State is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Step # 3 of filling in baltimore county domestic partnership

4. The subsequent section requires your input in the following parts: B Initial the box below if the, The Dependent is NOT married, C Initial the box by the statement, The Dependent is under the age of, Sole Support Affirmation for Other, I certify by my signature below, and Date. It is important to enter all requested details to move onward.

baltimore county domestic partnership completion process described (portion 4)

5. Because you come close to the finalization of your document, you will find a couple more requirements that should be fulfilled. Particularly, In some cases the dependent of, Initials, Qualifying Child Test Criteria, The child is my biological child, The child received over half of, divorced or legally separated, The child is in the custody of, The Child has not attained age, Initials, Qualifying Relative Test Criteria, and The Dependent has a specified should be done.

Step no. 5 of filling in baltimore county domestic partnership

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