AFFIDAVIT OF DOMESTIC PARTNERSHIP

I. Declaration

We, _________________________(Employee's Name) and _______________________, (Partner's Name) declare that:

1. We are unmarried.
   
   
2. We share the same primary residence and have been in a mutually exclusive relationship for the last twelve (12) months, intending to do so indefinitely.
   
   
3. We meet the age requirements for marriage in the State of New Mexico and are mentally competent to consent to contract.
   
   
4. We are not related by blood to the degree prohibited in a legal marriage in the State of New Mexico.
   
   
5. We are jointly responsible for the common welfare of each other and share financial obligations.

II. Change In Domestic Partnership

1. We agree to notify The University of New Mexico Human Resources Department in writing within thirty (30) days of any change in our status as domestic partners (for example, if we no longer share the same principal residence), or if we wish to terminate domestic partner benefits.

III. Dependent(s) of Domestic Partners

1. We declare as eligible dependent(s):
   
   ____________________________________________________________________________________
   
   ____________________________________________________________________________________
   
   ____________________________________________________________________________________
   (name[s] of child[ren] and initials of both partners).

IV. Acknowledgments

1. We understand that the value of tuition and insurance benefits provided to the domestic partner is considered taxable income to the employee by the Internal Revenue Service and is subject to social security and federal and state income tax withholding.
   
   
2. We understand that courts have recognized some non-marriage relationships as the equivalent of marriage for the purpose of establishing and dividing community property.
   
   

3. We acknowledge The University of New Mexico's advice that we consult an attorney before signing this document.  

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, disciplinary action, and that the employee is responsible for reimbursement to the University for any cost involved in providing benefit coverage.

EMPLOYEE'S SIGNATURE____________________________________ Date _________

DOMESTIC PARTNER'S SIGNATURE___________________________ Date _________

HUMAN RESOURCE REPRESENTATIVE ________________________ Date _________ 

STATE OF NEW MEXICO }Ss.
COUNTY OF BERNALILLO} The foregoing instrument was acknowledged before me this ____________ day of __________________, ________ by _____________________ and __________________________________________________ as their own free act and deed. _______________________________________________________________

Notary Public My Commission Expires: Date: _________________________ 

 Comments may be sent to UBPPM@UNM.edu
http://www.unm.edu/~ubppm