CITY OF SANTA MONICA AFFIDAVIT OF DOMESTIC PARTNERSHIP I, (herein referred to as the Employee), and (herein referred to as the Partner) hereby declare under penalty of perjury that we are domestic partners with the meaning of the following declaration: A domestic partner is a person, as of the date of enrollment, has executed and filed a Declaration of Domestic Partnership with the Secretary of State; or If we cannot provide documentation that we have registered our domestic partnership with the Secretary of State, we agree to provide the following: 1. Proof of cohabitation (i.e. Driver s License or Tax Return); and 2. Three or more of the following: a. Common ownership of real property or a common leasehold interest in such property b. Common ownership of a motor vehicle c. Joint bank accounts or credit accounts d. Designation as a beneficiary for life insurance or retirement benefits, or under the partner s will e. Assignment of a durable power of attorney or health care power of attorney f. Or such other proof as is sufficient to establish economic interdependency under the circumstances of the particular case. I declare and acknowledge that I and my domestic partner named above meet the following criteria: 1. are age of consent in the state of residence; and 2. are not related by blood in any manner that would bar marriage in the state of residence; and 3. have a close and committed personal relationship; and 4. have been sharing the same household on a continuous basis for at least 6 months; and 5. are not married to, or separated from, another individual; and 6. have not been registered as a member of another domestic partnership within the last 6 months. I acknowledge that: 1. I cannot file another Affidavit of Domestic Partnership for a new domestic partnership until at least six months after a Statement of Termination of Domestic Partnership has been filed. Affidavit of Domestic Partnership - Page 1
2. If requested, I will provide the City's Human Resources Department, or designated representative, documents establishing the existence of my domestic partnership relationship. 3. I have an obligation to file a Statement of Disenrollment, Death, or Termination of Domestic Partnership with the City's Human Resources Department or designated representative within 30 days of the earliest of (a) the death of my domestic partner; or (b) the date on which any of the criteria of a domestic partnership relationship is no longer met. 4. I further understand that the effective date of the end of the domestic partnership relationship is the earliest of (a) the death of my domestic partnership; or (b) the date on which I file a Statement of Disenrollment, Death, or Termination of Domestic Partnership with the City of Santa Monica's Human Resources Department. 5. I understand that I am responsible for reimbursement of any expenses incurred as a result of any false or misleading statement contained in this Affidavit of Domestic Partnership. I declare and acknowledge my understanding that: 1. The options under the group health coverage currently available to employees who choose to enroll their domestic partner may be more limited than those available to other employees due to the fact that some insurance carriers may refuse to extend coverage to domestic partners. 2. All group health coverage is governed by the terms of the underlying plan(s) ("Plan"). 3. For domestic partnerships, the City has no legal obligation to extend COBRA benefits, but the City has decided to offer limited continuation coverage to domestic partnerships. 4. Unless my domestic partner is also considered my dependent for tax purposes under Section 152(A) of the Internal Revenue Code, the Internal Revenue Service currently treats as imputed income to the employee the value of the health coverage provided domestic partners and their dependents, if any, less any contribution paid by the employee for this coverage. I acknowledge that there may be income tax liability as a result of obtaining health insurance for a domestic partner and his/her dependents. 5. I have an obligation to file a Statement of Disenrollment, Death, or Termination of Domestic Partnership with the City of Santa Monica's Human Resources Department within 30 days of the earliest of (a) the death of my domestic partner or (b) the date on which any of the criteria of a domestic partnership relationship is no longer met. 6. Regardless of whether the requisite Statement of Disenrollment, Death, or Termination of Domestic partnership has been filed, the effective date of the end of the domestic partnership relationship, and, therefore, the date on which coverage of my domestic partner and his/her dependent children, if any, will end, according to the terms of the Plan, is the earliest of: a. The date on which my domestic partner dies; b. The date on which the criteria of domestic partnership are no longer met; or c. The date on which I file a Statement of Disenrollment, Death, or Termination of Domestic Partnership with the City of Santa Monica's Human Resources Department. Affidavit of Domestic Partnership - Page 2
WHAT ARE THE TAX CONSEQUENCES OF ELECTING THIS BENEFIT? Unless the domestic partner is also considered the employee's dependent for tax purposes under Section 152 of the Internal Revenue Code, the Internal Revenue Service currently treats as imputed income to the employee, the value of the health coverage provided domestic partners and their dependents, if any, less any contribution paid by the employee for this coverage. The City of Santa Monica will compute the value of the imputed income resulting from the domestic partner benefit and the imputed income will be included on my W-2. Employees are advised to review the consequences of electing this benefit with their own tax advisors. ARE THERE OTHER LEGAL CONSEQUENCES TO ELECTING THIS BENEFIT? Employees wishing to opt for this benefit are advised to consult an attorney regarding the possibility that the filing of the Affidavit of Domestic Partnership may have other legal consequences, including the fact that it may, in the event of termination of the domestic partner relationship, be regarded as a factor leading a court to treat the relationship as the equivalent of marriage for the purpose of establishing and dividing community property, or for ordering payment of support. WHAT HAPPENS TO THE DOMESTIC PARTNER'S COVERAGE WHEN THE EMPLOYEE LEAVES EMPLOYMENT OR DIES? Although a domestic partner does not have the right to COBRA coverage under existing federal law, the City of Santa Monica has elected to allow a covered domestic partner, and his or her dependents, if any, to continue coverage at the COBRA rate applicable to the plan following: The employee's termination of employment, until the expiration of the employee's COBRA coverage, for up to 18 months. The death of the employee, up to 18 months. The domestic partner shall not be permitted to continue coverage beyond the date of the termination of the domestic partner relationship, or beyond the date that the domestic partner becomes eligible for coverage under Medicare. Coverage extension under the above circumstances is subject to the requirements and coverage extension limitations of the insurance companies underwriting the health plans. Affidavit of Domestic Partnership - Page 3
We declare under penalty of perjury under the laws of the state of California that each of us understands these rules and declares that the statements outlined above are true and correct with regard to the Employee s and Partner s domestic partner relationship. We understand that if the City of Santa Monica or their agents suffer any loss due to an inaccurate statement in this affidavit, they may bring civil action against either or both of us to recover their losses, including reasonable attorney s fees. We understand that the information contained in this affidavit will be held confidential and will be subject to disclosure only upon the express written authorization of the Employee or as required by law. Signature of Employee Signature of Domestic Partner SSN of Employee SSN of Domestic Partner Address: Phone: ( )_ Subscribed and sworn to before me this day of, 20_. Notary Public My commission expires Affidavit of Domestic Partnership - Page 4
CITY OF SANTA MONICA STATEMENT OF TERMINATION OF DOMESTIC PARTNERSHIP I,, affirm that the Affidavit of Domestic Partnership attested to and signed by me on shall be and is terminated as of this date. of Affidavit Termination is due to: Termination of domestic partnership because of a change in one or more of the circumstances attested to in the Affidavit. Death of domestic partner. I understand that I cannot file an Affidavit of Domestic Partnership to enroll a new domestic partner until six (6) months following the receipt of this Statement by the Fund. Signature of Employee Affidavit of Domestic Partnership - Page 5