[D]
Declaration of domestic Partnership
DOMESTIC PARTNER means a person in a domestic partnership with an employee or annuitant of the same sex.
DOMESTIC PARTNERSHIP means a committed relationship between two adults, of the same sex, that meets all of the requirements below.
We attest and declare that the following statements (A through G) are true and correct:
A. We are each other’s sole domestic partner and intend to remain so indefinitely;
B. We have a common residence and intend to continue the arrangement indefinitely;
C. We are at least 18 years of age and mentally competent to consent to contract;
D. We share responsibility for a significant measure of each other’s financial obligations;
E. Neither of us is married (legally or by common law) to, or legally separated from, anyone else;
F. Neither of us is a domestic partner of anyone else; and,
G. We are not related in a way that, if we were of opposite sexes, would prohibit legal marriage in the state in which we reside.
We also agree to, and understand that:
1. We must inform the appropriate employing agency or retirement system of the dissolution of this domestic partnership (which includes the death of either partner) not later than 30 days after we no longer meet the definition of domestic partnership;
2. Either domestic partner may inform the employing agency or retirement system of the dissolution of the domestic partnership; and,
3. Willful falsification of information within this document may lead to disciplinary action, loss of insurance coverage, and/or the recovery of the cost of benefits received related to such falsification.
PRINTED Name of Employee
Employee ID Number
Signature of the Employee_______________________________________________________________
Date Signed _ _/_ _/_ _ _ _
PRINTED Name of Domestic Partner
Signature of Domestic Partner ______________________________________________________________________
Date Signed _ _/_ _/_ _ _ _
Date Domestic Partnership Was Formed _ _/_ _/_ _ _ _
To complete the registration of this domestic partnership, you must mail this form to the Human Resources Shared Service Center (HRSSC), P.O. Box 970400, Greensboro, NC 27497-0400. Please keep a copy for your own records.
Privacy Act Statement: Your information will be used to process your Federal Long Term Care Insurance benefits request. Collection is authorized by 39 U.S.C. 401, 409, 410, 1001, 1005, 1206; and 29 U.S.C. 2601 et seq.
Providing the information is voluntary; but if not provided, your request may not be processed. We may disclose your information as follows: in relevant legal proceedings; to law enforcement when the U.S. Postal Service® (USPS®) or requesting agency becomes aware of a violation of law; to a congressional office at your request; to entities or individuals under contract with USPS; to entities authorized to perform audits; to labor organizations as required by law; to federal, state, local, or foreign government agencies regarding personnel matters; to the Equal Employment Opportunity Commission; and to the Merit Systems Protection Board or Office of Special Counsel.
USPS 104 FLTCIP Declaration
