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

AFFIDAVITOF MARRIAGE/SAME-SEX DOMESTIC PARTNERSHIP

I, _____________________________ SSN _____-______-______ certify that

Name of Faculty/Staff Member (print)

(Completeeither “A” or “B”):

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

Name andSSN of Spouse (print)

married on ___/___ /____

-OR-

B. I, and __________________________SSN _____-_____-_____became

Name and SSN ofSame-sex Domestic Partner(print)

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

1. Weare committed as a family in a long-term relationship ofindefinite duration and are

socially, emotionally, and financiallyinterdependent 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 toa degree of closeness which would prohibit legal marriage in

the state in which welegallyreside 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 ofthat change by filinga

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 anymarriage 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-sexDomestic

Partnership TerminationForm submission (or, if earlier, on the date ofdivorce or legal

separation ofa legal marriage); and

6. we understandthat benefits provided by Johns Hopkins University for a domestic partneror a

child ofa domestic partner generallywill be subject to federal (and possibly state)income tax

withholdingand also to Social Securityand 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 aSection 152 Dependent (as described

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

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

administrative purposes, as requiredby law or upon ourexpress writtenauthorization; and

8. we understand that anyperson’s eligibility for benefits is subject to auditing byJohns Hopkins

University and its agents for verification purposes; and

9. we understand thatlegal implicationsunder state and/orfederal lawmayexist due to the

declaration of responsibilityfor our common welfare; and

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

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

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

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

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

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

11.we understand that completing this Affidavit is onlyonerequirement for certain benefits and

that all eligibility requirements and other provisions ofallbenefit plans as well as policy

provisions of University programs willalso apply.

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

Print Name: ____________________________

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

Print Name: ____________________________

Return completed form to: Johns HopkinsUniversity, 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 thedefinition 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 taxpurposes.

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 Codesection 152 (referred to as “Section 152

Dependent” in this Affidavit)only if youprovide 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 asyour Section 152 Dependent forpurposesof these benefits for

a tax year only if (1) you provideover 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 adependent for federal tax

purposes. Additional rulesand restrictions may apply. You should consult with atax 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 purposesof medical, dental,and personal accident benefits and you do

not want to be taxedon the value of any of those benefitsprovided to your domestic

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

Bysigning below, I certifythat Ihave reviewed the requirements for a domestic partner or a

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

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

my domestic partner

the following child orchildren ofmy 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 promptlyinform the University ifany person indicated above

ceases to qualifyas my Section 152 Dependent while covered under any ofthese benefits.

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

Rev. October 2014 OBS