F- 4.10
MARIN COMMUNITY
COLLEGE DISTRICT
Human Resources
Department
AFFIDAVIT FOR
ENROLLMENT OF DOMESTIC PARTNERS
I,
________________________________________________________
(Print
Name of Qualifying Partner)
and
I, ________________________________________________________
(Print
Name of Domestic Partner)
certify that:
A. We are domestic partners of one another
within the following definitions:
DEFINITIONS
Qualifying Partner. Any full-time
permanent/probationary unit member who meets the criteria in B. 1. & 2. (a)
through (q).
Domestic Partner. Any partner
of a qualifying partner who meets the criteria in B. 1. & 2. (a) through
(q).
Domestic Partnership. Domestic partners are two persons, each aged 18 or
older, who have chosen to live together in a committed relationship, and who
have agreed to be jointly responsible for living expenses incurred during the
domestic partnership.
Live Together. "Live together" means
that two people share the same living quarters.
Each partner must have the legal right, documented in writing, to
possess the living quarters.
Living Expenses.
"Responsible for living expenses" means that the partners are
jointly responsible for the common welfare and financial obligations of each
other which are incurred during the domestic partnership.
B. ELIGIBILITY
AND ENROLLMENT CRITERIA
1. Each
of us understands that in order to enroll for coverage of the domestic partner,
each of us must complete, sign under penalty of perjury, and file with the
District an affidavit attesting to our meeting eligibility requirements, as
provided below.
2. Each
of us understands that in addition to meeting the definition of domestic
partnership provided in Section "A" above, we must satisfy the
additional eligibility criteria provided herein.
(a) Each
of us understands that the benefit must be one for which the qualifying
partner's spouse would be eligible, if the qualifying partner was married. Such benefits include medical, dental and
vision coverage. Retirement Medical insurance, Life Insurance and Disability
Insurance are not included. Each of us
further understands that benefits will not be provided for the dependents of
the domestic partner.
F 4.10
MARIN COMMUNITY
COLLEGE DISTRICT
Human Resources
Department
AFFIDAVIT FOR
ENROLLMENT OF DOMESTIC PARTNERS
Page 2 of 4
(b) We
are domestic partners according to the definition in Section "A"
above.
(c) We
have both reached the age of 18 and are mentally competent to consent to a contract.
(d) We
are each other's sole domestic partner.
(e) Neither
of us is married.
(f) Neither
of us has been a member of another domestic partnership within the previous six
months, unless that domestic partnership was terminated by death.
(g) Neither
of us is related to the other by blood as would prevent us from marrying under
California law (i.e., parent, child, sibling, half-sibling, grandparent,
grandchild, niece, nephew, aunt, uncle).
(h) We share the same principal place of
residence and intend to do so indefinitely.
Currently the address of our principal place of residence is:
_____________________________________________________________________
_____________________________________________________________________
(i) Each of us agrees that we both are
jointly responsible for the common welfare and financial obligations of each
other which are incurred during the domestic partnership. Each of us understands that our practice need
not be to contribute equally to the cost of the living expenses as long as we
agree that both of us are responsible for the total cost.
(j) Each of us understands and agrees that
the qualifying partner may make health plan and other benefit elections on
behalf of the domestic partner.
(k) Each of us acknowledges that the
District may require supportive documentation satisfactory to the District
concerning any and all eligibility criteria.
Such documentation may include a deed showing joint ownership of
property, a lease stating both partners' names as lessees, a joint bank
account, or other similar documentation.
(l) Each of us understands that in addition
to the eligibility requirements of the District for domestic partner coverage,
there are terms and conditions and limitations of coverage set forth in the
offered benefit plans themselves. Each
of us agrees that by executing the affidavit, each agrees to be bound by the
terms and conditions of coverage of the plans.
(m) Each of us understands that under
applicable federal and state tax law, District-provided benefits coverage of
the domestic partner could result in imputed taxable income to the qualifying
partner, subject to income tax withholding and applicable payroll taxes.
F 4.10
MARIN COMMUNITY
COLLEGE DISTRICT
Personnel
Department
AFFIDAVIT FOR
ENROLLMENT OF DOMESTIC PARTNERS
Page 3 of 4
(n) Each of us agrees to notify the District
within 30 days if there is any change of circumstances attested to in this
affidavit. The notice is to be in the
form of an amendment of this affidavit.
The domestic partner agrees that the qualifying partner may terminate the
domestic partner benefits unilaterally, at any time, irrespective of the view
of the domestic partner. If the
qualifying partner executes such an option, that qualifying partner shall
notify the domestic partner as soon as possible that his/her benefits have been
terminated and it shall be sole responsibility of that qualifying partner to
make such notification.
(o) Each of us understands that if either of
us has made a false statement regarding his or her qualification as a domestic
partner or has failed to comply with the terms of this affidavit, the District
shall have the absolute right to terminate any and all of the domestic
partner's benefits in accordance with the eligibility procedures specified in
the health benefits plan. Additionally, if the District suffers any loss
thereby, the District may bring a civil action against either or both of the
domestic partners to recover its losses, including reasonable attorney's fees
and court costs.
(p) Each of us understands and agrees that
the District Administrator of any benefit plan will initially determine whether
a domestic partner is qualified for benefits. Disputes shall be resolved as
provided for in Article 16 of the agreement.
(q) Each
of us declares under penalty of perjury under the laws of the State of
California that the assertions in this Affidavit are true and correct.
_________________________________ ____________________
Signature of Qualifying Partner Date
of Birth
_________________________________ ____________________
Signature of Domestic Partner Date of Birth
F 4.10
MARIN COMMUNITY
COLLEGE DISTRICT
Human Resources
Department
AFFIDAVIT FOR
ENROLLMENT OF DOMESTIC PARTNERS
Page 4 of 4
State of California )
)
ss.
County of Marin )
On this __________day of_________________, in the
year 20__, before me, _______________________________, a Notary Public, State
of California, duly commissioned and sworn, personally appeared
___________________________________ and
__________________________________ personally known to me (or proved to
me on the basis of satisfactory evidence) to be the persons whose names are
subscribed to within this instrument and acknowledged to me that they executed
the same in their authorized capacities, and that by their signatures on this
instrument the persons executed this instrument.
WITNESS my hand and official seal.
__________________________________________
NOTARY PUBLIC, STATE OF CALIFORNIA
My commission expires:_____________________
DOMESTIC.DOC