Affidavit of Domestic Partnership Enrolling a same-gender Domestic Partner in Group Benefits Federated Department Stores, Inc., its divisions and subsidiaries continue to recognize the value of diversity in our work force. As a result, the Health Care Program, Optional Group Life Insurance Program and Optional Group Accidental Death & Dismemberment Program provide coverage for eligible domestic partners as described in this brochure. Review this brochure if you have a same-gender domestic partner and wish to cover your domestic partner and/or your domestic partner s children in: ΠΠHealth Care Coverage ΠLife Insurance Coverage Accidental Death & Dismemberment Coverage Same-gender and opposite-gender domestic partners who are California residents must file a Declaration of Domestic Partnership with the Secretary of State under provisions of the California Insurance Equality Act. They are not required to complete Federated s Affidavit of Domestic Partnership. 1-800-337-2363 This summary is an overview only. The terms and conditions of the benefits discussed in this guide are determined solely by the summary plan descriptions or plan documents of the Plans described herein. The Company reserves to itself, pursuant to its sole and exclusive discretion, the right to change, amend or terminate the plan without regard to satisfaction of eligibility conditions. Benefits described herein many not automatically apply to associates covered under a labor agreement.
About Domestic Partnerships and Group Benefits Plans 1. What is domestic partnership? As defined in The Federated Health Care Plan, The Federated Optional Life Insurance Plan and The Federated Optional Accidental Death & Dismemberment (AD&D) Plan, a domestic partnership is a long-term relationship of indefinite duration between adults of the same gender who (i) have an exclusive, mutual commitment similar to that of marriage, (ii) have agreed to be responsible for each other s welfare, (iii) would be married, if same-gender marriages were permitted under the laws of the state in which they reside, and (iv) meet the following other requirements: a) are not related by blood, b) are not married to or legally separated from anyone else, c) are at least 18 years of age and meet the marriage age requirement of the state in which they reside, d) currently share a household, have been doing so continuously for at least 12 months, and plan to continue to do so indefinitely, e) have filed a domestic partnership agreement or registration if available in their state (and/or city) of residence, and f) are financially interdependent as can be demonstrated by i) joint ownership of real property, ii) common ownership of an automobile, iii) joint bank accounts, iv) driver s license listing a common address, v) assignment of a durable property power of attorney or health care power of attorney, or vi) a will, retirement plan, or life insurance policy designating the other as primary beneficiary. 2. What is required to provide coverage to my domestic partner? An Affidavit of Domestic Partnership is required if you have a same-gender domestic partner and wish to do one or more of the following: ΠEnroll a domestic partner in health care overage ΠElect Domestic Partner Life Insurance coverage ΠElect Child Life Insurance coverage for the dependent child or children of a domestic partner ΠElect Individual + Family AD&D coverage Note to California residents: The associate and domestic partner who are residents of California must file a Declaration of Domestic Partnership with the Secretary of State under provisions of the California Insurance Equality Act. They are not required to complete Federated s Affidavit of Domestic Partnership. However, Federated and/or the health care option in which you enroll may request a copy of a valid Declaration of Domestic Partnership. 3. Should I seek legal counsel before signing the Affidavit of Domestic Partnership? You are encouraged to seek advice of legal counsel concerning the legal implications of signing the Affidavit of Domestic Partnership, for example, to your ownership of property. California residents are not required to complete the affidavit, but must file a Declaration of Domestic Partnership with the Secretary of State under provisions of the California Insurance Equality Act. 4. What if the law in my state changes to permit same-gender marriages? If the law in the state in which you reside changes to permit same-gender marriages, you and your domestic partner must marry within a reasonable time in order to continue participation for the domestic partner in health care, Spouse/Domestic Life Insurance and/or Individual + Family AD&D coverage. 5. What if our Affidavit of Domestic Partnership is rejected? You may request a review for reconsideration by following the procedures detailed in the summary plan description booklet for each plan. 6. How do I enroll my domestic partner or children of my domestic partner in coverage? ΠMake sure your partnership qualifies. Read the information in this brochure and the affidavit carefully. ΠComplete and sign the Affidavit of Domestic Partnership in the presence of a notary public and return it to Federated HR Services. (The associate and domestic partner who are residents of California must file a Declaration of Domestic Partnership with the Secretary of State under provisions of the California Insurance Equality Act. They are not required to complete Federated s Affidavit of Domestic Partnership.) ΠEnroll in the health care, life insurance and/or AD&D programs either on-line or by completing and returning an Election Form to Federated HR Services. You may enroll in coverage on an after-tax basis only. ΠIf more information is needed, the carrier will correspond directly with you once advised of your enrollment. Before coverage can be effective, ALL required information must be supplied for review by Federated and/or the carrier. ΠIf additional documentation is requested at any time by Federated, the carrier or the insurer, you must provide the documentation within 30 days of the request. Failure to do so will result in cancellation of coverage for the domestic partner.
About the Health Care Program 7. Is my domestic partner eligible for health care coverage even if no Federated-sponsored options where I live or work make it available? Unfortunately, although we include this provision as a part of our health care program, individual health care options do not always provide coverage to domestic partners. If this is the case in your area, your domestic partner will not be able to enroll. 8. Are the children of my domestic partner also eligible to join my health care coverage? The health care program permits legal dependents of the domestic partner to enroll if they reside in the home of the associate and meet the eligibility requirements of dependents as defined in the health care program. 9. If my domestic partner and I become parents through birth or adoption, may I add our new child to health care coverage? If domestic partners have a child through birth or adoption and the associate has added the domestic partner to health care coverage, you must call Federated HR Services within 31 days of the birth or adoption to request the required forms to add the child effective with the date of birth or adoption. If you do not, your next opportunity to add the child to coverage is effective with annual enrollment the next July 1. 10. May I enroll my domestic partner or children of my domestic partner in health care coverage at any time? The health care program eligibility guidelines state that you may only add a domestic partner to your coverage at your initial eligibility or effective with annual enrollment July 1 if permitted by your health care option. In addition, in order to enroll a new domestic partner, 12 months must have elapsed since termination of Company-provided coverage for a previous domestic partner of the employee. 11. What will it cost to cover my domestic partner and the children of my domestic partner in health care coverage? The regular Associate + One or Associate + Family contributions will apply and will be deducted on an after-tax basis. Federal regulations pertaining to Federated s Flexible Compensation Plan require this since a domestic partner and the children of your domestic partner are not your legal dependents. In addition, tax regulations require the Company to report the value of the coverage for the domestic partner and the covered dependents of the domestic partner, less the associate contribution, as taxable income to you. This is referred to as imputed income. Imputed income is subject to federal tax, applicable state/local tax and FICA withholdings. 12. How is imputed income calculated for my health care contributions? For those enrolling a domestic partner in health care coverage, imputed income will be calculated and taxes adjusted on your pay advice at least monthly. Although the figures used in the following example are not actual contributions, it is an example of how monthly imputed income will be calculated if you enroll a domestic partner only. If you enroll a domestic partner and the children of your domestic partner, use the Associate + Family contribution instead of the Associate + One contribution. Imputed Income Example Step 1 Step 2 Step 3 Determine the value of the coverage for the domestic partner by subtracting the total Associate Only contribution from the total Associate + One contribution. ( Total contribution includes both the employer and the associate contributions for coverage.) Sample Associate + One Contribution Sample Associate Only Contribution Value of Domestic Partner coverage $300.00/month - 150.00/month $150.00/month Determine the difference between the associate s cost for Associate Only and Associate + One coverage. Sample Associate + One Contribution Sample Associate Only Contribution Difference in Contributions $150.00/month - 75.00/month $ 75.00/month Determine the imputed income by subtracting the difference in the associate contributions in Step 2 from the value of domestic partner coverage in Step 1. Value of Domestic Partner Coverage (from Step 1) Difference in Contributions (from Step 2) Imputed Income $150.00/month - 75.00/month $ 75.00/month
13. How can I estimate the imputed income for my health care contributions and for which I will be responsible? You can use this worksheet to calculate your imputed income when covering a domestic partner only. If you enroll a domestic partner and the children of your domestic partner, use the Associate + Family contribution instead of the Associate + One contribution. You will need to contact Federated HR Services to obtain information such as Total Contribution. Be sure the contributions you request are per pay period so you will be able to more accurately determine your imputed income. Imputed Income Worksheet Step 1 Step 2 Step 3 Determine the value of the coverage for the domestic partner by subtracting the total Associate Only contribution from the total Associate + One contribution. ( Total contribution includes both the employer and the associate contributions for the coverage.) Associate + One Contribution Associate Only Contribution Value of Domestic Partner coverage - Determine the difference between the associate s cost for Associate Only and Associate + One coverage. Associate + One Contribution Associate Only Contribution Difference in Contributions - Determine the imputed income by subtracting the difference in the associate contributions in Step 2 from the value of domestic partner coverage in Step 1. Value of Domestic Partner Coverage (from Step 1) Difference in Contributions (from Step 2) Imputed Income - 14. May I drop my domestic partner or children of my domestic partner from health care coverage at any time/? Because coverage for a domestic partner and dependent children of a domestic partner is paid for on an after-tax basis, you may drop coverage at any time. Call Federated HR Services for instructions to drop coverage if desired. 15. Are my domestic partner and children of my domestic partner eligible for continuation health care coverage under COBRA law? Continuation coverage, similar to that made available under the federal law known as COBRA, will be available to the domestic partner and dependent children of the domestic partner in the event that coverage ends. Information to elect continuation coverage will be mailed to the domestic partner s address of record. Questions? I have further questions about coverage for my domestic partner or children of my domestic partner. Who can I ask? Federated HR Services will be happy to assist you if you have any questions. Call (800) 337-2363. 1-800-337-2363
AFFIDAVIT OF * 0 1 1 0 0 0 0 0 0 0 0 0 * DOMESTIC PARTNERSHIP Employee Name Employee SSN Division For purposes of enrolling my Domestic Partner or my Domestic Partner s child(ren) in Group Benefits (health care, life insurance and/or accidental death and dismemberment coverage) provided for employees of Federated Department Stores, Inc., or a subsidiary or division thereof (the Company ), we hereby attest that we are Domestic Partners and meet the definitions and requirements for Domestic Partnership as set forth below: Definition of Domestic Partnership: A long-term relationship of indefinite duration between adults of the same gender who (i) have an exclusive, mutual commitment similar to that of marriage, (ii) have agreed to be responsible for each other s welfare, (iii) would be married, if same-gender marriages were permitted under the laws of the state in which they reside, and (iv) meet the following other requirements: a) are not related by blood, b) are not married to or legally separated from anyone else, c) are at least 18 years of age and meet the marriage age requirement of the state in which they reside, d) currently share a household, have been doing so continuously for at least 12 months, and plan to continue to do so indefinitely, e) have filed a domestic partnership agreement or registration if available in their state (and/or city) of residence, and f) are financially interdependent as can be demonstrated by i) joint ownership of real property, ii) common ownership of an automobile, iii) joint bank accounts, iv) driver s license listing a common address, v) assignment of a durable property power of attorney or health care power of attorney, or vi) a will, retirement plan, or life insurance policy designating the other as primary beneficiary. We agree to provide documentation promptly to verify any of the above requirements. We understand that failure to provide such documentation within 30 days of request will result in cancellation of health care coverage. We understand that in order for the employee to enroll a new Domestic Partner, 12 months must have elapsed since termination of Company-provided health care, optional life insurance and/or accidental death & dismemberment coverage for a previous Domestic Partner of the employee. If enrolling in health care coverage, we understand that employee contributions for health care coverage will be paid only on an aftertax basis, that the employer contribution for health care coverage of the Domestic Partner and dependent children of the Domestic Partner will be reported as income to the employee and will be taxable to the employee, and that continuation coverage will be available to the Domestic Partner or dependent child of the Domestic Partner in the event that coverage ends for any reason. We understand that the availability of health care coverage for Domestic Partners and/or dependent children of Domestic Partners provided by the Company is subject to state regulation and the approval of the health care options providing health care benefits, and may be changed or terminated at any time. If enrolling Domestic Partner in Domestic Partner life insurance and/or Domestic Partner s child(ren) in Child life insurance coverage and/or Individual + Family accidental death and dismemberment coverage, we understand that the availability of life insurance and accidental death and dismemberment coverage is subject to the approval of the insurer(s) providing benefits, and may be changed or terminated at any time. We also understand that if the law in the state in which the undersigned employee and Domestic Partner reside changes to permit same-gender marriages, Domestic Partners residing in that state must marry in order to continue their participation in health care, life insurance and/or accidental death and dismemberment coverage. We understand that there may be additional legal implications to the signing of this Affidavit relating, for example, to our ownership of property, and that we have been encouraged to seek legal advice before signing this Affidavit. We understand that any misrepresentation on this Affidavit may result in termination of the employee for cause. Employee Signature Domestic Partner Signature Date Date Subscribed and sworn to me this day of Notary Public Keep a copy for your records. Mail to: Federated HR Services, P.O. Box 8083, Mason, OH 45040.
1-800-337-2363