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Affidavit of Termination of Domestic Partnership

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                                                   Affidavit of Termination of
                                                     Domestic Partnership

                 I, __________________________________ , ________________________________,
                       (Employee's Name - Print)                         (Employee's Social Security Number - Print)
                 previously filed with the University an Affidavit of Domestic Partnership for selected fringe
                 benefits. I now inform the University that ________________________________ is no
                                                                      (Name of Former Domestic Partner - Print)
                 longer my domestic partner as of _________________.
                                                             (Date)


                 I understand that by filing this Termination of Domestic Partnership my former domestic
                 partner may no longer be eligible for fringe benefit plans in which he/she were formerly
                 enrolled. This ineligibility also extends to the legal dependents of my former domestic
                 partner.


                 I understand that by filing this Termination of Domestic Partnership that a subsequent
                 Affidavit of Domestic Partnership may not be filed for at least 6 months.



                 ________________________________________             ______________________
                 (Signature of Employee)                               (Date Signed)




                 Please return completed form to the Office of Human Resources.

                  Print Form        Clear Form

                                         Submit this form to your Payroll and Benefits Office




UWS-51 12/02

				
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