Master Agreement 2005 - State Employment Relations Board

Domestic Partners Benefit Forms
Affidavit of Same Sex Domestic Partnership
Columbus City School District
Affidavit uf Same Sex Domestic Partnership
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is my domestic partner and that:
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I. We share a permanent residence (unless residing in different cities, states, or
countries on a temporary basis).
2. We are in a long-term committed relationship and have been in this
relationship for at least six (6) months.
3. We are of the same gender as each other and we are each other's sole
domestic partner and intend to remain so indefinitely.
4 . We are responsible for each other's common welfare.
5. We are at least eighteen ( 18) years of age or older.
6. We are not legally married to anyone.
7. We are no t re lated by blood closer than would bar marriage in the State of
Ohio.
8. We are mentally compete nt to consent to contract.
9. We share financial obligations, as demonstrated by the existence of at least
two of the fo llowing Conditions (please check those that apply)
___ A. We have common or joint ownership of a residence (house,
condominium, or mobile home). (Deed/Title)
___ B. We share at least two of the following:
(1) Joint ownership of a motor vehicle (Title)
(2) Joint checking account (Bank Statement)
(3) Joint credit account (Statement)
) -
(4) Residential lease identifying both partners as tenants (Lease)
C. My domestic partner has been designated as a primary beneficiary of at
--- least of one of the following:
(1) My Columbus City Schools Term Life Insurance
(2) My w ill
(3) A trust
NOTE: At least two (2) documents are required to prove the existence of the abovementioned
conditions.
I agree to file, within 30 days of the termination of my domestic pannership, an Affidavit
of Termination of Domesti c Partnership with the Human Resources Office affirming that
the domestic partnership has been terminated a nd that a copy of the Affidavit of
Terminatio n of Domestic Partner Status has been mailed to my previous panner. I
understand that another Affidavit of Domestic Partnership cannot be filed until six (6)
months after th e most recent domestic partnership has been tenninated.
I understand the information in this affidavit will be used by the School District for the
sole purpose of determining my eligibility for domestic partnership benefits. This
informati on will be treated as confidential to the extent permitted by Ohio law and wil l be
used solely for the administration of benefits by Columbus City Schools Human
Resources Office. I understand that availability of these benefits is based on el igibility
requirements a nd subject to changes in program provisions and Ohio law.
I, the undersigned Columbus City Schools employee, understand that falsification of
info rmation in this affidavit may lead to disciplinary action, up to and including
termination fro m employment.
Signature of E mployee Date of Birth Date
CCSD ID Number: _______ _
Signature of Witness Date
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