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    Chabot Las Positas Community College District Office of Human Resources Domestic Partnership: Affidavit

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    Dioner Ray
    This document is an affidavit for establishing a domestic partnership between an employee and their partner to receive benefits from the CHABOT­LAS POSITAS COMMUNITY COLLEGE DISTRICT. It requires both individuals to declare under penalty of perjury that they meet the qualifications of having an intimate relationship, living together, agreeing to share basic living expenses, both being at least 18 years old, unmarried, not related, and not having a different domestic partner in the last 6 months. It also provides definitions for "living together" and "basic living expenses" and notes that the affidavit must be notarized before it can be submitted to establish the domestic partnership.

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    © All Rights Reserved
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    Chabot Las Positas Community College District Office of Human Resources Domestic Partnership: Affidavit

    Uploaded by

    Dioner Ray
    30 views2 pages
    This document is an affidavit for establishing a domestic partnership between an employee and their partner to receive benefits from the CHABOT­LAS POSITAS COMMUNITY COLLEGE DISTRICT. It requires both individuals to declare under penalty of perjury that they meet the qualifications of having an intimate relationship, living together, agreeing to share basic living expenses, both being at least 18 years old, unmarried, not related, and not having a different domestic partner in the last 6 months. It also provides definitions for "living together" and "basic living expenses" and notes that the affidavit must be notarized before it can be submitted to establish the domestic partnership.

    Original Description:

    Domestic Partnership: Affidavit

    Original Title

    DomesticPartnershipAffadavit4313-fillable

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    This document is an affidavit for establishing a domestic partnership between an employee and their partner to receive benefits from the CHABOT­LAS POSITAS COMMUNITY COLLEGE DISTRICT. It requires both individuals to declare under penalty of perjury that they meet the qualifications of having an intimate relationship, living together, agreeing to share basic living expenses, both being at least 18 years old, unmarried, not related, and not having a different domestic partner in the last 6 months. It also provides definitions for "living together" and "basic living expenses" and notes that the affidavit must be notarized before it can be submitted to establish the domestic partnership.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    30 views2 pages

    Chabot Las Positas Community College District Office of Human Resources Domestic Partnership: Affidavit

    Uploaded by

    Dioner Ray
    This document is an affidavit for establishing a domestic partnership between an employee and their partner to receive benefits from the CHABOT­LAS POSITAS COMMUNITY COLLEGE DISTRICT. It requires both individuals to declare under penalty of perjury that they meet the qualifications of having an intimate relationship, living together, agreeing to share basic living expenses, both being at least 18 years old, unmarried, not related, and not having a different domestic partner in the last 6 months. It also provides definitions for "living together" and "basic living expenses" and notes that the affidavit must be notarized before it can be submitted to establish the domestic partnership.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    CHABOTLAS POSITAS COMMUNITY COLLEGE DISTRICT

    Office of Human Resources


    Domestic Partnership: Affidavit

    IDECLAREUNDERPENALTYOFPERJURYUNDERTHELAWSOFTHESTATE
    OF CALIFORNIATHATTHESTATEMENTSBELOWARETRUEANDCORRECT.

    1. Wehaveanintimate,committedrelationshipofmutualcaring
    2. Welivetogether(seedefinitiononthenextpage)
    3. Weagreetoberesponsibleforeachother'sbasiclivingexpenses(seedefinitiononthenext
    page)duringourdomesticpartnershipwealsoagreethatanyonewhoisowedthese
    expensescancollectfromeitherofus
    4. Weareboth18orolder
    5. Neitherofusismarried
    6. Neitherofusisrelatedtotheother
    7. Neitherofushasadifferentdomesticpartnernow
    8. Neitherofushashadadifferentpartnerinthelastsixmonths(thislastcondition
    doesnotapplyifyouhadapartnerwhodiedifyoudid,crossthisout).

    WedeclareunderpenaltyofperjuryunderthelawsoftheStateofCaliforniathatthe
    statementsabovearetrueandcorrect.
    (PleasePrint)

    Date:____/____/____

    EmployeesName:_______________________________________________________
    (Last)(First)(Middle)

    DomesticPartnersName:_________________________________________________
    (Last)(First)(Middle)

    SharedResidenceAddress:____________________________________________________________
    (Street&Number)(City)(State/Zip)

    Employee'sSignature:________________________________Signedon:____/____/____

    DomesticPartnersSignature:__________________________Signedon:____/____/____

    Updated06/20083/21/13
    P:/FORMS/Faculty200708/DomesticPartnershipAffidavitUpdtd.doc
    PageTwo
    DomesticPartnership:Affidavit

    DEFINITIONS:

    "Livetogether"meansthatthedomesticpartnersshareaplacetolive.

    "Basicliving expenses" means the cost of basic food and shelter. It also includes
    any other expense, which ispaid by a benefit either partner receives becauseof
    the partnership. For example, domestic partners who receive health insurance
    coveragearemutuallyresponsibleformedicalbills,whichtheinsurancedoesnot
    pay. It is not necessary to actually split basic living expenses to be domestic
    partners.Thepartnersjusthavetoagreetoprovidethesethingsfortheirpartnerif
    thepartnerisunabletoprovideforhimorherself.

    THELASTSTEP:

    Tocompletesettingupadomesticpartnership,youmustsignthisforminfront
    ofaNotaryPublic,havetheNotaryfillinthenotarizationatthebottomofthispage,
    andsubmittheAffidavittotheOfficeofHumanResources,7600DublinBoulevard,
    3rd Floor,DublinCA94568.

    NOTARIZATION:

    Stateof________________________________,Countyof__________________
    on____/____/____beforeme,__________________________________________
    Date NameandTitleofOfficer(e.g.,"JaneDoe,NotaryPublic")
    Personallyappeared:

    ________________________________________________________________
    Name(s)ofSigners

    Whoprovedtomeonthebasisof satisfactoryevidencetobetheperson(s)whose
    name(s)is/aresubscribedtothewithininstrumentandacknowledgedtomethat
    he/she/theyexecutedthesameinhis/her/theirauthorizedcapacity(ies),andthatby
    his/her/theirsignature(s)ontheinstrumenttheperson(s),ortheentryuponbehalfof
    whichtheperson(s)acted,executedtheinstrument.

    IcertifyunderPENALTYOFPERJURYunderthelawsoftheStateofCalifornia
    thattheforegoingparagraphistrueandcorrect.

    WITNESSmyhandandofficialseal,

    SignatureofNotaryPublic _____________________________________________

    Reference: Article20A.3,20A.3bFacultyCollectiveBargainingAgreement

    Updated06/20083/21/13
    P:/FORMS/Faculty200708/DomesticPartnershipAffidavitUpdtd.doc

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