Affidavit of Domestic Partnership Enrollment Form

I, , submit this Affidavit of Domestic Partnership to establish (print – Name of Employee)

,as my Domestic Partner (as this term is defined below) for the purpose of (print – Name of Domestic Partner)

obtaining any health benefits Teva may extend to Domestic Partners of its employees.

I affirm as follows: and I are Domestic Partners. (sign – Name of Employee) (sign – Name of Domestic Partner)

Teva defines Domestic Partners as two adults of the same or opposite sex who have been in a relationship of mutual caring, reside together and share a mutual obligation for basic living expenses for at least six months.

I affirm that as of the date of this Affidavit my Domestic Partner and I meet all of the criteria noted on this Affidavit and that, upon request by the employer, I must provide acceptable substantiation of same within 10 days of the request:

We have shared the same residence together for at least six months and intend to do so permanently. Note: It is not necessary that the legal right to possess the residence be in both of their names (i.e., the lease or deed need not be in both names).

We have been financially interdependent for at least six months and intend to continue to be financially interdependent permanently.

In addition, if we live in a jurisdiction that permits registration of Domestic Partners, I acknowledge that my Domestic Partner and I have registered, or will register within the next 30 days, as Domestic Partners in that jurisdiction.

I understand that:

I have an obligation to file an Affidavit of Termination of Domestic Partnership with the Benefits Department within 30 days of the earliest of:

a. the death of Domestic Partner; or

b. the date on which any of the criteria of a Domestic Partner relationship is no longer satisfied.

In either event, benefits for my Domestic Partner will cease.

Teva will not extend Cobra Benefits to a Domestic Partner or his/her dependents.

I cannot file another Affidavit of Domestic Partnership for a new Domestic Partner until at least six months after I file an Affidavit of Termination of Domestic Partnership.

I understand that I am responsible for reimbursement of expenses incurred as a result of any false or misleading statements contained in this Affidavit of Domestic Partnership. I understand that any false or misleading statements herein may constitute fraud and subject me to termination, civil and/or criminal penalties.

I understand that I may wish to consult appropriate counsel regarding the possible consequences of filing this Affidavit. Possible consequences include, but are not limited to, (1) the possible treatment by a court, in the event of termination of this relationship, as the equivalent of a marriage for the purpose of establishing and dividing communication property and as for ordering payment of support, (2) an impact on state income taxes and (3) the inclusion as taxable wages to the employee of health benefits provided to an employee’s domestic partner (or to a dependent(s) of the employee’s domestic partner), who does not qualify as a spouse or dependent in accordance with IRS rules. The taxable amount is excess of the fair market value of the medical and dental plan coverage over the amount paid by the employee.

We are not related by blood to a degree of closeness that would prohibit legal marriage in the state of legal residence.

We are both at least 18 years of age and mentally competent.