AFFIDAVIT OF DOMESTIC PARTNERSHIP
MEA Anthem Blue Cross Blue Shield Health Plan
Employee’s School Name____________________
A. Partner Certification
We, ______________________________________ and ________________________________ certify that we are
domestic partners in accordance with the following criteria and eligible for benefits coverage under a group health benefit
1. We are each other’s sole domestic partner and intend to remain so indefinitely.
2. We are jointly responsible for each other’s common welfare, share financial obligations and share our primary
residence. We are enclosing evidence of joint responsibility. [Joint responsibility may be demonstrated by the
existence of two or more of the following. (Please check at least two items that apply.)]
Domestic Partnership Agreement or Relationship Contract
The Domestic Partner has been designated as a beneficiary of employee’s will, or retirement contract. I.e. life
insurance, MSRS annuities, 401K, 403B
Joint mortgage or joint ownership of a primary residence
Two of: _____ Joint ownership of a motor vehicle
_____ Joint checking account Two of these count as one requirement
_____ Joint credit card account
_____ Joint lease
3. We are: Not married to anyone, and
at least eighteen (18) years of age and mentally competent to consent to contract, and
not related by blood to a degree of closeness which would prohibit marriage in the State of Maine
Our domestic partnership agreement or relationship contract (as defined in items 1 through 3 above) has been in
existence for at least twelve (12) months prior to the effective date of this affidavit.
We understand that domestic partners are subject to the other eligibility provisions of the benefit plan.
Domestic Partners are not eligible for continuation of benefits under COBRA. We agree to notify the employer sponsoring
this plan within thirty (30) days of the termination of our domestic partnership. A written termination statement shall be
provided and shall affirm that the partnership is terminated and that a copy of the termination statement has been mailed
to the other partner, the school, and Anthem Blue Cross Blue Shield of Maine.
We certify, under penalty of perjury, that the foregoing is true and correct. We, the undersigned employee and the
Domestic Partner, understand that falsification of information contained in this Affidavit may lead to disciplinary action and
may subject us to civil action to recover any losses, including reasonable attorney’s fees incurred by the MEA Anthem
Blue Cross Blue Shield Health Plan or by its insurance carrier for benefits provided under the MEA Anthem Blue
Cross Blue Shield Health Plan.
Employee Signature____________________________________________________ Date_______________________
Social Security Number___________________________ Phone #: (home)_______________ (work)_______________
Address: _____________________________________________ City______________________ Zip_____________
Domestic Partner Signature:_______________________________________________ Date______________________
Social Security Number_________________________________
STATE OF MAINE
The above parties, proven to be, have signed and dated this document in my presence this ___________ day
of ______________________________, in the year ____________________.