Fillable Printable Affidavit of Marriage/Same-Sex Domestic Partnership - Johns Hopkins University

Affidavit of Marriage/Same-Sex Domestic Partnership - Johns Hopkins University

Human Resources

Benefits Service Center

Johns Hopkins at Eastern

1101 East 33

Street, Suite D200

Baltimore, MD 21218

JOHNS HOPKINS UNIVERSITY

AFFIDAVIT OF MARRIAGE/SAME-SEX DOMESTIC PARTNERSHIP

I, _____________________________ SSN _____-______-______ certify that

Name of Faculty/Staff Member (print)

(Complete either “A” or “B”):

A. I, and _______________________SSN _____-_____-_____were legally

Name and SSN of Spouse (print)

married on ___/___ /____

-OR-

B. I, and __________________________SSN _____-_____-_____became

Name and SSN of Same-sex Domestic Partner (print)

same-sex domestic partners on ___/___ /____, and we certify the following to be true:

1. We are committed as a family in a long-term relationship of indefinite duration and are

socially, emotionally, and financially interdependent with each other in an exclusive mutual

commitment in which we agree to be responsible for each other’s common welfare and share

financial obligations; and

2. we are not related by blood to a degree of closeness which would prohibit legal marriage in

the state in which we legally reside and our relationship does not violate state or local law;

and

3. we agree to notify Johns Hopkins University if there is any change in our status of marriage or

domestic partnership as certified in this statement within thirty days of that change by filing a

Marriage/Same-sex Domestic Partnership Termination Form; and

4. we were competent to consent to contract when our marriage or domestic partnership began;

and

5. we understand that any marriage or domestic partnership recognized by the University based

on this affidavit will be treated as terminated for benefits purposes upon the death of my

spouse/domestic partner or on the date indicated in a Marriage/Same-sex Domestic

Partnership Termination Form submission (or, if earlier, on the date of divorce or legal

separation of a legal marriage); and

6. we understand that benefits provided by Johns Hopkins University for a domestic partner or a

child of a domestic partner generally will be subject to federal (and possibly state) income tax

withholding and also to Social Security and Medicare taxes based on the fair market value of

those benefits and any employee contributions for coverage for those benefits must be made

on an after-tax basis unless the faculty or staff member signs the statement at the end of this

Affidavit to certify that the partner or child qualifies as a Section 152 Dependent (as described

later in this Affidavit) of the faculty or staff member for tax purposes; and

7. we understand that this information will be held confidential but is subject to disclosure for

administrative purposes, as required by law or upon our express written authorization; and

8. we understand that any person’s eligibility for benefits is subject to auditing by Johns Hopkins

University and its agents for verification purposes; and

9. we understand that legal implications under state and/or federal law may exist due to the

declaration of responsibility for our common welfare; and

10. we understand that if we make a false statement or misrepresentation on this Affidavit of

Marriage/Same-sex Domestic Partnership, the University reserves the right to take any and all

actions necessary to deny benefits or to recover amounts paid for benefits to which a person

was not entitled, as well as any expenses or attorney fees incurred by the University in an

attempt to recover such amounts and that any false statements on this Affidavit may lead to

other disciplinary action, up to and including termination of employment.

11. we understand that completing this Affidavit is only one requirement for certain benefits and

that all eligibility requirements and other provisions of all benefit plans as well as policy

provisions of University programs will also apply.

Faculty/Staff Member’s Signature: ____________________________ Date:___/ ___/___

Print Name: ____________________________

Spouse/Domestic Partner’s Signature: ____________________________ Date:___/ ___/___

Print Name: ____________________________

Return completed form to: Johns Hopkins University, Benefits Service Center, Johns

Hopkins at Eastern, 1101 East 33

Street, Suite D200, Baltimore, MD 21218, or fax form to

443-997-5820.

NOTE: You should review the definition below and sign the statement below if you intend to

elect any type of coverage for your domestic partner or any child of your domestic partner, if you

conclude that your partner or your partner’s child is your dependent for tax purposes.

Internal Revenue Code Section 152 Definition of Dependent

For purposes of the University’s medical, dental, and personal accident benefits, a domestic partner

generally will be your dependent under Internal Revenue Code section 152 (referred to as “Section 152

Dependent” in this Affidavit) only if you provide over one-half of your partner’s financial support and your

partner lives with you during the entire tax year. A child of your domestic partner who is not your adopted

or biological child generally will qualify as your Section 152 Dependent for purposes of these benefits for

a tax year only if (1) you provide over one-half of the child’s support, (2) the child lives with you and (3)

neither your domestic partner nor any other taxpayer claims the child as a dependent for federal tax

purposes. Additional rules and restrictions may apply. You should consult with a tax adviser if you have

any question about whether your domestic partner or a child qualifies as your dependent for tax

purposes.

If your domestic partner or any child of a domestic partner qualifies as a Section 152

Dependent for purposes of medical, dental, and personal accident benefits and you do

not want to be taxed on the value of any of those benefits provided to your domestic

partner or a child of a domestic partner, you must complete the following:

By signing below, I certify that I have reviewed the requirements for a domestic partner or a

child of a domestic partner to be treated as my Section 152 Dependent for purposes of the Plan

and that the following person or persons (check appropriate box or boxes):

 my domestic partner

 the following child or children of my domestic partner (list by name):

_______________________

qualify as my Section 152 Dependents for purposes of the Plan’s medical, dental or personal

accident benefits. I agree to promptly inform the University if any person indicated above

ceases to qualify as my Section 152 Dependent while covered under any of these benefits.

Faculty/Staff Member’s Signature: ____________________________ Date:___ /__/__

Rev. October 2014 OBS