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domestic partner affidavit form 2011-2012.pdf

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					                                                                                                WSU Student Medical Insurance Plan
                                                                                               Affidavit of Domestic Partnership Form

I. Declaration

We, ___________________________________ and _________________________________, declare that:
         (Student’s Name)                          (Domestic Partner’s Name)

1. We are unmarried.

2. We have shared the same primary residence and have been in a mutually exclusive relationship for the last six (6)
   months, intending to do so indefinitely.

3. We meet the age requirements for marriage and are not related by blood to the degree prohibited in a legal marriage in
   the State of Washington.

4. We were both of sound mind and mental competence at the time of contract consent.

5. We are jointly responsible for “basic living expenses” as defined in section 2, Qualifying Criteria, of the Domestic

II. Change In Domestic Partnership
Upon termination of the domestic partnership or a change in the status of the conditions outlined above, we agree that we
must notify HWS at Washington State University within thirty (30) days.

III. Dependent(s), of Domestic Partners
We declare as eligible dependent(s):

Name(s) of child(ren)                                                             Initials of both partners

_______________________________________                                             _______   _______

_______________________________________                                             _______   _______

IV. Acknowledgements
1. We understand that this affidavit shall be terminated upon the death of either domestic partner or by a change of my
circumstance attested to in this affidavit.

2. We agree to inform HWS of any change in circumstances attested to in this affidavit within thirty (30) days of the change

3. Upon termination of the domestic partnership, we understand that any benefits provided to us through the University as a
result of the partnership, shall be terminated on the first day of the month following loss of eligibility.

We affirm, under penalty of perjury, that the assertions in this Statement are true and correct. We understand that any
misrepresentation of fact may result in loss of benefits and that the student is responsible for reimbursement to the Insurance
Company for any claims paid if the partner is found to be ineligible for enrollment.

__________________________________ __________                                                 ____________________________________   ________
Student’s Signature                Date                                                       Domestic Partner’s Signature           Date

__________________________________ __________
HWS Representative                 Date
\\Hws-svr1\studentinsurance\Forms\2009-2010\Domestic Partner Affidavit Form 2009-2010.Doc

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