Certification of Marriage or Domestic Partnership

Declaration of Dependents

SECTION I (Please print):

Employee: __________________________________________________________________
Last Name First MI

Spouse: __________________________________________________________________
Last Name First MI

Domestic
Partner: __________________________________________________________________
Last Name First MI

Dependents:
Date Relationship to
Name Of Birth Social Security # Employee
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

SECTION II
Relationship Certification

A. To be completed by MARRIED EMPLOYEE

Signature Date

B. To be completed by EMPLOYEE WITH DOMESTIC PARTNER

Signature Date

C. Address of Spouse or Domestic Partner if different from the employee:

_____________________________________________________

_____________________________________________________

_____________________________________________________

SECTION III
Definitions and Documentation

A. Spouse: A person to whom you are currently married as recognized under New York or other applicable law.
B. Domestic Partner: A same sex or opposite sex partner to whom you are not married. There must exist between
the employee and his/her domestic partner a responsibility for each other’s financial and general welfare
equivalent to that established for married couples within the statutes of the State of New York or the state
whose law otherwise applies. Neither partner may be under the age of 18. Each of the partners must be
mentally competent to enter into a legally binding contract. The employee and his/her domestic partners may
not be related by blood closer than would bar marriage in the State of New York, or the state whose law
otherwise applies.
C. An employee may not certify more than one spouse or domestic partner at any one time.
D. Eligible dependents are those dependents that either meet the IRS definition of dependency under Section 152
of the Internal Revenue Code or are court-mandated dependents, for Health Benefits. Documentation of
dependency may be required by the Colleges at any time. Acceptable documentation includes a current tax
return or a copy of the relevant court order of support.
E. Documentation of marriage or domestic partnership may be required by the Colleges at any time. Acceptable
documentation includes:
 A valid copy of the marriage certificate, or
 Copies of at least three of the following:
 A valid copy of the registration of the domestic partnership with Monroe County or any other
municipal registry accepted by the Colleges.
 Evidence of joint residence. Appropriate documentation would include any of the following;
 Evidence of joint purchase of a home
 A copy of a lease for a residence identifying both parties as responsible for payment of rent
 Other evidence of joint residence such as
 The addresses on drivers’ licenses
 The addresses on voters’ registrations
  The addresses on passports
 Evidence of a joint checking account
 A title for a car showing joint ownership
 Evidence of joint liability for credit cards
 Evidence that the spouse/domestic partner is the primary beneficiary of the employee’s 403(b)
retirement account and life insurance
 Evidence of durable powers of attorney for property or health
 Wills specifying the spouse/domestic partner as the major recipient of employee’s financial assets or
the administrator of the assets if the dependents, certified above, are the major recipients.

F. If appropriate documentation, as specified above, is not provided by the employee within 30 days of a request
for documentation by the Colleges, the spouse/domestic partner will be immediately ineligible for Health
Benefits.

SECTION IV
Change in Status

Marriage Status or Domestic Partnership

I agree to notify the Hobart and William Smith Colleges’ Human Resources Office if there is any change in our
status (marriage or domestic partnership), as certified in this statement, which would make the spouse/domestic
partner no longer eligible for Health Benefits. I will notify the Human Resources Office within 30 days of the
change by filing a Statement of Termination. The Statement of Termination shall affirm that the marriage or
domestic partnership is terminated or no longer eligible for Health Benefits and that a copy of the Statement of
Termination has been mailed to the other party by the employee.

Dependent Status

I further agree to notify the Colleges’ Office of Human Resources if there is any change in the status of any of my
dependents which would make him or her ineligible for benefit coverage. Such notification of change in status must
be communicated in writing to Human Resources within 30 days of the change.

Signature Date

SECTION V
Acknowledgements

In completing and signing this certification form, I am aware of and agree to the following terms and conditions:

1. False Certification
I understand that falsely certifying eligibility, or otherwise misstating, misrepresenting or omitting facts
relevant to eligibility may result in disciplinary action (including dismissal). I further understand that such
conduct may subject me to civil and/or criminal prosecution for benefits wrongfully obtained and that I may
become liable for such benefits and expenses associated with the recoupment (including reasonable attorney’s
fees).
2. Tax status of Health care Premiums paid by the Colleges on behalf of domestic partners.
I understand that the Internal Revenue Service regulations do not exempt benefit premiums paid by an
employer on behalf of an employee’s domestic partner. For this reason the Colleges may automatically include
the value of any health care contribution or COBRA equivalent in my taxable income.
3. Confidentiality
 I understand this application and the information contained in it will be maintained by the Colleges written
consent except as necessary to provide benefits coverage or otherwise as a confidential personal document, and
shall not be disclosed in the absence of the employee’s required by law.
4. Affirmation
I affirm that the assertions in this document are, to the best of my knowledge, true and accurate.

Signature Date