Fillable Printable Affidavit of Marriiage or Domestic Partnership - Willamette University
Fillable Printable Affidavit of Marriiage or Domestic Partnership - Willamette University
Affidavit of Marriiage or Domestic Partnership - Willamette University
Willamette University
Human Resources
AFFIDAVIT OF MARRIAGE OR DOMESTIC PARTNERSHIP
SECTION I - Certification of Marriage or Domestic Partnership
I, (name of undersigned Willamette University faculty or staff
member) certify that (please complete “A” or “B” or “C”):
A. Marriage
(name of spouse) and I were legally married on _____
(date)
in the State of ________________________________________ .
Move to Section II
B. Unregistered Domestic Partnership
(name of domestic partner) and I entered into an effective
domestic partnership as of ________ (date), as defined by Willamette University below:
• We share the same regular and permanent residence.
• We share an ongoing, personal and committed relationship which we have with no other and which is
comparable to marriage.
• We either are not legally permitted to marry or choose not to marry for ethical or other significant
personal reasons.
• We are jointly responsible for each other’s welfare and the maintenance of our household as
demonstrated by several of the following: a written domestic partnership agreement; a joint real
estate mortgage, lease or deed; current beneficiary designation naming the domestic partner as a
primary beneficiary of life insurance, retirement plan or a will; joint ownership of a motor vehicle; joint
checking and/or savings account; or a joint credit account.
• Neither of us is married to anyone else.
• Each of us is eighteen years of age or older.
• We are not related by blood closer than would bar marriage in the state of Oregon.
• We were mentally competent to consent to contract when our committed partnership began.
The fair market value of a benefit may be taxable. In addition, domestic partners, registered or
unregistered, may not be beneficiaries under Flexible Spending programs. Please consult with your tax
advisor before checking the appropriate box below:
I certify that the previously named person is my legal tax dependent under IRS Sec. 152.
OR
I certify that the previously named person is not my legal tax dependent under IRS Sec. 152.
Move to Section II
SECTION II - Understandings
We provide the information in this Affidavit to be used by Willamette University for the sole purpose of
determining our eligibility for marital or domestic partnership benefits. We understand that we are
subject to all other eligibility provisions of relevant benefit plans.
We understand that this Affidavit will be confidentially maintained in Human Resources and will only be
subject to disclosure to persons whom the University determines to have a need to know for verification
of eligibility, benefits, payroll, accounting, and auditing purposes.
We understand that a spouse or domestic partner is eligible for continuation of benefits upon termination
of marriage or domestic partnership. For a spouse this continuation is available under the provisions of
the Consolidated Omnibus Budget Reconciliation Act (COBRA). The university extends eligibility for
continuation of benefits to domestic partners under same standards as provided under COBRA.
I understand that this Affidavit shall be terminated upon the death of my spouse or domestic partner or
by a change of the circumstances attested to in this Affidavit. I agree to notify the Willamette University
Human Resources Department if there is any change of the circumstances attested to in this Affidavit
within thirty days of the change by filing a Statement of Termination of Marriage or Domestic Partnership
and by providing a copy of the Statement to the spouse or domestic partner named in this Affidavit.
After such termination, I understand that another Affidavit cannot be filed for an Unregistered Domestic
Partnership until six months after a Statement of Termination of Marriage or Domestic Partnership has
been filed with Willamette University Human Resources Department.
NOTICE: This affidavit of marriage or domestic partnership may have legal implications under Oregon
state law. If you desire further information concerning the possible legal consequences of signing this
form, please consult an attorney.
We have read and fully understand this Affidavit. We declare that the statements in this Affidavit are true
and correct to the best of our knowledge.
Willamette University Faculty or Staff Member Date
Spouse or Domestic Partner Date
C. Oregon Registered Same-Sex Domestic Partnership
(name of domestic partner) are registered as domestic
partners under Oregon Law as of ________ (date).
Registered domestic partnership in Oregon does not provide for benefits of marriage under Federal law.
Please be advised that the fair market value of a benefit may be taxable. In addition, domestic partners,
registered or unregistered, may not be beneficiaries under Flexible Spending programs. Please consult with
your tax advisor before checking the appropriate box below:
I certify that the previously named person is my legal tax dependent under IRS Sec. 152.
OR
I certify that the previously named person is not my legal tax dependent under IRS Sec. 152.
Move to Section II
