Con fiden tial

MONROE COUNTY COMMUNITY SCHOOL CORPORATION AFFIDAVIT OF DOMESTIC PARTNERSHIP

Employee Name (Last, First, Middle):

-Date of Birth: IGender (Circle One)

M F I SOCi~1 Security Number

..\ ddress: I City I State I Zip Code

Employee Information

Domestic Partner Information Name (Last, First, Middle): I PaltlllOrship Began On:

Date of Birth: Gender (Circle One): I Social Security Number

Address: ICity: I M F

.----,--IState: I Zip:

Domestic Partner Dependent Child Information (List only tht doml'Slic p~rlner's unrn~rritrl biolo:::ical or

,'doplcd dlild(rcnlwho arc il) Ill{' ('uslOdv and care of Ih(' dumestic "arluer lind arc a InelUbel' of the cnlployce'~ houschohJ)

O(p(l1d<.:nl Child Nome (La,t. First, Middle) SCK'I ul Security NIImba Dale of [3irtlJ RC M<JHicu Full'linlC $llldenl

YIN YIN YIN YIN

RC (Relationship Code): DS = biologica1or adopted son of domestic pa rtner oD = biologici'll or adopted dl! ughter of domestic pa rtner

DECLARATION

We, the undersigned, declare that: (1) \Ve are at least 18 years of age and competent to enter into a contract

(2) We are the same sex and, lherefore, prevented from marrying in Indiana.

(3) We arc not married [lnd are not the domestic parlner of any other persOll,

(4) We are not related Illy blood closer than would bar us t"i'ol11lllarriage in the state of Indiana

(5) We have been living together as a couple and share a residence and have done so for more than six (6) consecutive months prior to this declaration.

(6) At least six months have passed since the termination of any previous same-sex domestic partnersh ip.

(7) We attest that our relationship is an exclusive mutual commitment that is the functional equivalent of a marriage: that is,

• we arc jointly responsi ble for each other for the necessities of life inc Iud ing each other's debts: and

• we intend to remain in the relationship indefinitely: and • we wou lei enter into a legal marriage if the 0PPoJ1unity were ava ilable: and

• we have agreed that in the event of dissolution of our domestic partner relationship, we will make a substantially equal division of any earnings acquired during Our domestic pattnership and of property acquired with those earnings; that is, a division of properry si milar to that legally requ ired of a married cou pie in the event of a divorce.

(8) In lieu of the marriage certificate that MCCSC requires to cover an employee's spouse, we are submitting the following supporting documentation to verify our interdependent financial relationship: ­

a.) Joint ownership of residence (home, condo, mobile home) or a lease for a residence identifying both partners as tenants, (lnd

b.) Two or the follo",ing: joint ownership of a motor vehicle; joint credit aCCOllnt; joint checking account; or other evidence of joint ownership of a major asset or joint li"bility of debt.

ACKNOWLEDGEMENTS

I) We have read and understand the eligibility requirements, employee responsibilities, and tZlX infonnation described in Same Sex Domestic Portner Beneflts--Program ]J?(ormation Sheet.

2) Mccse has advised us to consult with an attorney regarding the legal consequences of signing this declaration; for example, whether this document can be used by creditors to hold One palincr responsi ble for the debts of the other or whether a partner may use th is document as evidence of entitlement to division of property acquired during the partnership.

3) We waive, release, and indemnify MCCSC from all claims and causes of action that may arise as a result of MCeSC affording benefits to or certifying domestic partnerships

4) MeCSC's cost for providing domestic partners benefits and the employee's payroll contribution will generally be taxable income to the employee unless the domestic partner and partner's dependent eh iIdren are qURI ified tax dependents of the employee's.

5) The employee is responsible for notifying Mecsc by submitting a 'Terminution ofa Domestic P(/rlner~h;p' notice form within 60 d<Jys of the date that we no longer meet the el igibility requirements for domestic pal1ner benefits.

6) This affidavit is requested for the purpose of MeeSe making a determination of our eligibility for domestic partner benefits provided by MCCSC; that this information will be held confidentially, but will be disclosed as needed to arrange benel-its with applicable third pZlrty administrators or as required by law or a court: and that Mcesc may be required to make the records of th is domestic partnersh ip BV" ilable to the publ ic under the Freedom of In formation Act.

7) We understand that MCCSe may change benefits coverage and eligibility at any time.

8) We understand that MCeSC will require annual fe-certification of eligibility for domestic partnersh ip.

CERTIFICATION We certify that the forgoing information is true <lnd correct <lnd understand that a false decimation of a domestic partnership or failure to file a timely notice of' Termination ofa Domestic Partnership' with the MeeSe Human Resources Department may result in disciplinary action Lip to and including termination of employment at MeeSe. We agree that in the event of a false deciMation, or the fai lure to file a 'Termination of (l Domestic Partnership' notice form with Mccse, MeeSe may recover damages from either or both of liS for all costs and expenses incurred by MCCSC as a result of that false declaration, including, without being limited to, attorneys) fees incurred by MCCSe to recover such damages.

Employee Signature Date Domestic Pcllinel' Signature Dale

NOTARIZATION: STATEOF __ COUNTYOF __

The foregoing affidavit was acknowledged before me this ~~~_day of~~ ,20

By: ~~~~~~ . Notary Public My Commission Expires: _

1- For MeeSe Use Only

I Affidavit and supporting documentation received and approved by on, _ i