Attachment 4 - Technical Exhibt Affidavit of Domestic Partnership.pdf
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- Attached to
- OCC Group Life Insurance (OGLI) Services (RFP)
- Solicitation number
- 2031JW26R00001
About this file
The document is an Affidavit of Domestic Partnership form issued by the Office of the Comptroller of the Currency (OCC), U.S. Department of the Treasury. The form requires two individuals to declare their domestic partnership status, confirming they are 18 or older, mentally competent, not blood-related in a way that would bar marriage, and have been sharing a permanent residence for at least six months.
The affidavit includes three key sections: a domestic partner statement, signature section, and notary public acknowledgment. Signatories agree to notify the OCC of any changes in their partnership status and understand that providing false information could result in the rescission of relocation benefits and potential liability for repayment of relocation expenses. The form is designed to be completed, signed, and notarized to validate the domestic partnership for potential employer relocation benefits.
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Text version
Affidavit of Domestic Partnership Section 1: Domestic Partner Statement
The undersigned, being duly sworn, depose and declare as follows:
We are each eighteen years of age or older and mentally competent.
We are not related by blood in a manner that would bar marriage under the laws of the State of ___________________________.
We have a close and committed personal relationship, and we are each other’s sole domestic partner not married or partnered with any other spouse, spouse equivalent or domestic partner.
For at least six months we have shared the same regular and permanent residence in a committed relationship and intend to do so indefinitely.
Section 2: Domestic Partner Signatures
Each of us agrees to notify the OCC if there is any change in our status as domestic partners as attested to in this Affidavit.
Each of us understands and agrees that in the event any of the statements set forth herein are not true, the relocation benefits for which this Affidavit is being submitted may be rescinded and/or each of us shall jointly and severally be liable for repayment of relocation expenses reimbursed by the employer.
Print name Print name
Signature Signature
Section 3: Notary Public Acknowledgment
The foregoing document was acknowledged before me this ________ day of ________________________, 20__ by _____________________________________.
Notary Public
Affidavit of Domestic Partnership
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File details come from the government source that posted it. Updated .