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DECLARATION OF DOMESTIC PARTNERSHIP

Washington and Lee University extends the same benefits to persons who meet the University's definition of domestic partner that the University extends to spouses of employees, to the extent permitted by law and by the underwriting guidelines imposed by the insurance companies. The inclusion of domestic partner coverage in W&L's benefit program is consistent with the University's dedication to non-discriminatory practices and represents a commitment to remain competitive in the recruiting of new faculty and staff.

A domestic partner is an unrelated adult of the same or opposite sex of the employee with whom the employee is living in an intimate, long term relationship with an exclusive commitment similar to marriage, in which the partners are jointly responsible for one another's welfare and share financial obligations. The following must apply in order to qualify for benefits:

I. DECLARATION

* Name of Subscriber:

* Subscriber Email Address:

* Name of Domestic Partner

We declare that we are domestic partners in accordance with the criteria set forth below:

We are both at least eighteen years old and competent to consent to contract.
We are not married or legally separated from anyone else.
We are not related by blood to a degree of closeness that prohibits legal marriage in the state in which we reside.
We are engaged in a committed and exclusive relationship of mutual caring and support and are jointly responsible for each other's common welfare and share financial obligations; documentation for this interdependence can be provided if requested.
This relationship has been in existence for at least six months with the expectation that it will continue indefinitely.
We are not in this relationship solely for the purpose of obtaining coverage.

II. DOCUMENTATION

Just as with legal marriage, Washington and Lee University reserves the right to request adequate documentation of domestic partner relationships. Any or all of the following would constitute valid evidence of such a relationship:

shared residence
joint mortgage or rental lease
joint ownership of a motor vehicle
joint checking account
joint credit account
designation of domestic partner as primary beneficiary in employee's will
designation of domestic partner as primary beneficiary on retirement and/or life insurance contract
durable power of attorney given to domestic partner

We agree to notify the Human Resources Department within thirty-one (31) days of the termination of a domestic partner relationship (i.e., the date that any of the criteria in Section I above is no longer accurate). Upon termination of a domestic partner relationship, the employee and the domestic partner must wait at least six months before reapplying for domestic partner benefits.

We affirm that all declaration statements and proof of interdependence are truthful and accurate and that we understand our responsibility to notify the Office of Human Resources by the completion of a Declaration of Termination of Domestic Partnership within thirty-one (31) days of the time that any of the declaration statements are no longer accurate.

* Employee Signature:

* Domestic Partner Signature: