Affidavit of Domestic Partnership

If domestic partners want to share financial obligations in a relationship similar to marriage, they have to execute this affidavit.

Extracted Text for Proper Search

AFFIDAVIT OF DOMESTIC PARTNERSHIPRELATING TO BENEFITS PROVIDED BY THE CITY OF ST. LOUIS A DOMESTIC PARTNER is defined as an unrelated adult of the same or oppositesex of the employee with whom the employee is living in an intimate, long-termrelationship with an exclusive commitment similar to marriage, in which the partnersare jointly responsible for one another’s welfare and share financial obligations.DECLARATIONThe undersigned, being duly sworn, depose and declare as follows:1.We are each eighteen years of age or older and mentally competent.2.We are not related by blood in a manner that would bar marriage under the laws of theState of Missouri.3.We have a close and committed personal relationship, and we are each other's soledomestic partner not married to or partnered with any other spouse or domestic partner.4.For at least 6 months immediately preceding the date of this Affidavit, we have shared thesame regular and permanent residence in a committed relationship and intend to do so indefinitely.5.We are jointly financially responsible for basic living expenses defined as the cost of food,shelter, and other expenses of maintaining a household. Upon request by the City of St.Louis, we will provide within 5 calendar days at least two of the following documents asverification of our joint responsibility (information should be dated to confirm eligibility attime of enrollment):a)  Joint mortgage or lease;b)Designation of the domestic partner as primary beneficiary for a life insurance policy;c)Designation of the domestic partner as primary beneficiary in the employee’s will;d)Durable power of attorney for health care or financial management;e)Joint ownership of a motor vehicle, a joint checking account, or a joint credit account;f)A relationship or cohabitation contract which obligates each of the parties to providesupport for the other party, or other evidence that establishes economic interdepen-dence;g)Registration as domestic partners with the City of St. Louis in accordance withOrdinance 64401.6.We understand that under applicable federal income tax law, payments for medical anddental coverage of a domestic partner may not be eligible for pre-tax treatment.7.We understand that in addition to the City of St. Louis eligibility requirements, there areterms and conditions of coverage set forth in the Service Agreement of each insurance planoffered through the City of St. Louis to which we agree to be bound.8.We understand and agree that insurance is provided only insofar as such coverage is per-mitted under law and the City of St. Louis’ contracts with its health insurance providers; andany insurance provided may be limited, curtailed or revoked as necessary to comply withlaw and the City of St. Louis’ contracts with its health insurance providers.  We also under-stand and agree that the City of St. Louis shall be free to revoke or rescind coverage fordomestic partners and/or their dependents at any time for budgetary reasons or when suchaction is in the best interest of the City of St. Louis.

9.We understand and agree that in the event any of the statements set forth herein are nottrue, the insurance coverage for which this Affidavit is being submitted may be rescindedand/or each of us shall jointly and severally be liable for any expenses incurred by the Cityof St. Louis, the insurer or health care entity.______We certify that the domestic partner and his/her child(ren), if any, aremembers of the employee’s household.  The employee providesmore than 50% of his/her/their financial support. We are aware thatdependent medical and/or dental deductions may be made on a pre-tax basis.______We certify that the domestic partner and his/her child(ren), if any, aremembers of the employee’s household. The employee does not pro-vide more than 50% of his/her/their financial support.  We are awarethat dependent medical and/or dental deductions cannot be made ona pre-tax basis.                                                                                                                                  We certify that the foregoing is true and accurate to the best of our knowledge. We also under-stand and agree that in the event any of the statements set forth herein are not true, the insurancecoverage for which this Affidavit is being submitted may be rescinded and/or each of us shall jointlyand severally be liable for any expenses incurred by the City of St. Louis and/or the insurer.IMPORTANT NOTICE:  The City of St. Louis is not a tax advisor and bears no responsibility for the determination madeconcerning dependent eligibility status, or any tax consequences thereof, under the Internal Revenue Code.  You shouldcontact your tax advisor regarding dependent eligibility status and the tax consequences of such determination, and anyother tax consequences under the Internal Revenue Code. We have been provided with written material regarding our rights and responsibilities relating to domestic partner cover-age.  By signing this form we evidence our understanding of the information provided.________________________________________________________________Signature of EmployeeSignature of Domestic Partner________________________________________________________________Print NamePrint Name________________________________________________________________Employee Social Security NumberDate________________________________Date05/05