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Affidavit of Termination of
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 _________________.
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
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.
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Submit this form to your Payroll and Benefits Office