/depts/,/depts/uwhealth/,/depts/uwhealth/benefits/,/depts/uwhealth/benefits/open-enrollment/,/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/,/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/domestic-partner/,/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/domestic-partner/resources/,

/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/domestic-partner/resources/UWMF-2018-Domestic-Partner-Affidavit-DRAFT-9.29.17.pdf

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Departments & Programs,UW Health,Benefits,UW Health Open Enrollment,UWMF Open Enrollment,Domestic Partner,Resources

Domestic Partner Affidavit

Domestic Partner Affidavit - Departments & Programs, UW Health, Benefits, UW Health Open Enrollment, UWMF Open Enrollment, Domestic Partner, Resources


UWMF 2018 Domestic Partner Affidavit

Employee Information
Name (first, middle, last) Employee ID

Birth Date

Effective Date of Domestic Partnership

Domestic Partner Information
Name (first, middle, last)

Social Security Number

Contact Phone Number

Birth Date

Gender (M/F)

Address Information of residence shared by both domestic partners
Street Address

City

State ZIP Code
Mailing Address (if different than above)

City

State

ZIP Code


This Affidavit affirms a Domestic Partnership relationship only for the following UW Health (UWMF) purposes:
ξ UW Medical Foundation employees – benefits enrollment, bereavement, Personal Medical Leave and WMFLA

We affirm that we are in a domestic partner relationship and that this Domestic Partnership relationship has been in existence for a
period of six (6) consecutive months prior to our signature on this Affidavit.

Domestic partners must have at least two (2) of the following and provide supporting documentation. Please check which supporting
documentation is being provided:
Joint ownership or common leasehold in a residence;
Joint ownership of motor vehicle;
Joint ownership of a checking account or credit account;
Designation of the domestic partner as beneficiary for the employee’s life insurance or retirement benefits;

We affirm that our partnership complies with all of the following criteria:
ξ Neither the domestic partner nor the employee has entered into the relationship for the purpose of obtaining insurance
coverage;
ξ On the date this document was signed, both of us are legally competent and at least 18 years of age;
ξ Neither of us is married to or in a domestic partnership with another person;
ξ We are not related by blood in any way that would prohibit marriage under Wisconsin’s laws;
ξ We consider ourselves to be members of each other’s immediate family;
ξ We agree to be responsible for each other’s basic living expenses; and
ξ We share a common residence. You are considered to share a common residence even if any of these conditions apply:
o Only one partner has legal ownership of the residence
o One or both partners have additional residences not shared by the other partner
o One partners leaves the common residence with the intent to return

We understand that any person, employer or company who suffers any loss because of false statements contained in a “Domestic
Partner Affidavit” may bring civil action against us to recover the losses, including reasonable attorney fees.

We understand the information in this affidavit will be used by the employer for the sole purpose of determining our eligibility for
Domestic Partnership benefits. We further understand that this information will be held confidential and will be subject to disclosure
only upon our expressed written authorization or pursuant to a court order.

We affirm, under penalty of perjury, that the statements in this Affidavit are true and correct to the best of our knowledge.

Employee Signature Domestic Partner Signature Date