Affidavit of Domestic Partnership at a glance
What it is: Affidavit of Domestic Partnership: you certify that the Domestic Partner is a Domestic Partner of the Employee/Retiree.
Who signs: Employee/Retiree Signature: sign under SIGN and enter the Date. Domestic Partner Signature: sign and enter the Date.
Notary: Complete and attach the notarized Affidavit of Domestic Partnership to your Benefit Event or Enrollment Form. Notary seal and signature must be clearly visible.
What to bring and attach to Affidavit of Domestic Partnership
In addition to this Affidavit, attach at least two of the documents listed. One of the submitted documents must prove the domestic partnership was established at least 12 months prior to the date of this affidavit. The documents are: joint mortgage or lease; designation of Domestic Partner as beneficiary for life insurance and retirement contract; designation of Domestic Partner as primary beneficiary in employee's or insured's will; durable property and health care powers of attorney or Maryland Certification of Domestic Partnership; joint ownership of motor vehicle, joint checking account or joint credit account.
A filled-in Affidavit of Domestic Partnership example: two partners sign before a notary
How to fill out Affidavit of Domestic Partnership, box by box
Names and the date of the Domestic Partnership
Enter the Employee/Retiree's Name under Affidavit of Domestic Partnership.
After you certify that, write the Domestic Partner's name (please print) and, after a Domestic Partner of, the Employee/Retiree's name (please print).
Enter the Date after Domestic Partnership as of: you certify you met the following eligibility criteria for establishing a Domestic Partnership.
The eligibility criteria: You have lived together for at least twelve months. You are not married, have not been married for at least the previous 12 months, and have no other Domestic Partner. You are at least 18 years of age and mentally competent to consent to contract. You reside together in the same residence and intend to do so indefinitely. You have an exclusive mutual commitment similar to that of marriage. You are jointly responsible for each other's common welfare and share financial obligations.
Change in Domestic Partnership
Change in Domestic Partnership: you agree to notify the State of Maryland within thirty (30) days of any change in Domestic Partnership status which would make the Domestic Partner no longer eligible for benefits (e.g., a change in joint residency,) by filing a Statement of Termination of Domestic Partnership.
Upon termination of this Affidavit of Domestic Partnership (evidenced by a Statement of Termination of the Partnership signed by the Insured), write your name after I; you agree that another Affidavit of Domestic Partnership cannot be filed for a minimum of twelve months.
Signatures
ACKNOWLEDGEMENTS: you have provided the information in this Affidavit for the sole purpose of determining your eligibility for Domestic Partnership
Willful falsification of information within this document may lead to disciplinary action, loss of insurance coverage, and/or the recovery of the cost of benefits received related to such falsification.
Employee/Retiree Signature: sign under SIGN and enter the Date.
Enter the Employee/Retiree Social Security number and the Employee and Domestic Partner Home Address.
Domestic Partner Signature: sign and enter the Date.
Notary
The Notary Public fills in On this day of, 20, before me personally came, the individual described as Employee/Retiree/Insured and the individual described as Domestic Partner in the document entitled AFFIDAVIT OF DOMESTIC PARTNERSHIP, who executed same as a free and voluntary act for the uses and purposes stated herein, and signs with My Commission Expires.
Sources
[1] Affidavit of Domestic Partnership, Maryland Department of Budget and Management (the Official source link on this page).