Attachment_5_-_Technical_Exhibit_Domestic_Partner_Affadavit.pdf

CC-6026-23 (Rev 12/05)

AFFIDAVIT OF DOMESTIC PARTNERSHIP FOR BENEFITS COVERAGE

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 to or partnered with any other spouse, spouse equivalent or domestic partner.

We are in a committed, personal, financially interdependent relationship in which we mutual agree to be responsible for each other’s common welfare and share financial obligations.

For at least six months we have shared the same regular and permanent residence in a committed relationship and intend to do so indefinitely.

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set forth herein are not true, the insurance or health care coverage for which this Affidavit is being submitted may be rescinded and/or each of us shall jointly and severally be liable for any expenses incurred by the employer, insurer or health care entity.

Print Name Print Name

Signature Signature

Sworn to before me this _____day of ____________________, 200___.

NOTARY PUBLIC

ATTACHMENT 5