Declaration
of
Domestic Partnership:
FEHB and FEDVIP
DOMESTIC PARTNER
means a person
in
a domestic partnership
with
an employee
or
annuitant
of the
same
sex.
DOMESTIC PARTNERSHIP
means
a
committed relationship between
two
adults,
of
the same sex,
that
meets
all of
the requirements
below.
We attest and declare
that the
following statements (A through H) are
true
and
correct:
A.
We are each other’s sole domestic partner and
intend to
remain so
indefinitely;
B.
We have a common residence and
intend to
continue the arrangement
indefinitely;
C.
We are
at
least 18 years
of
age and mentally competent
to
consent
to contract;
D.
We share responsibility
for
a significant measure
of
each other’s financial
obligations;
E.
Neither
of us is
married (legally
or
by common law)
to, legally separated from, or joined in a civil
union with anyone else;
F.
Neither
of us is
a domestic partner
of
anyone
else;
G.
We are not related in a way that, if we were of opposite sex, would prohibit legal marriage as of the day before
the current open season, or;
H. Either (select applicable situation):
□
For Stepchildren to be Covered Effective in January 2014, or Other Open Season Enrollments or
Changes:
We would marry but for the state of our residence
[____]
to permit same-sex marriage as of the
day before the current open season,
or;
STATE
□
For Stepchildren to be Covered as a Qualifying Life Event:
We would marry but for the state of our
residence
[____]
to permit same-sex marriage as of the date I am signing this declaration.
STATE
We also agree to, and understand that:
1.
We
must inform
the appropriate employing agency
or
retirement system
of
the dissolution
of this
domestic partnership (which includes the death
of
either partner)
not
later than 30 days after
we
no
longer meet the
definition of
Domestic
Partnership;
2. Either domestic partner may
inform
the employing agency
or
retirement
system
of
the
dissolution
of
the domestic partnership;
3.
A child's continued eligibility for FEHB/FEDVIP coverage as a stepchild who is the child of a
same-sex domestic partner must be determined on an annual basis at Open Season. We
understand that, should the laws in our state of residence change prior to the next Open
Season to permit same-sex couples to marry, or if we move to a state that permits same-sex
marriage, and we choose not marry, we will inform our employing office or retirement system
that our child's coverage must be terminated for the following plan year;
and,
4.
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.
PRINTED Name
of Employee/Annuitant
Last
name
First
name M.I.
Signature
of
Employee/Annuitant
Date
Signed
/
/
Social Security number
or
Other Employee
Identifier
Civil Service Retirement number (CSA
or
CSF),
if applicable
