Statement of Termination Of Domestic Partnership

I, ___________________________________________ _______________________________
(Name of Employee – Print)

Employee ID Number (required)

certify that I previously filed the appropriate Affidavit of Domestic Partnership with the Office of
Human Resources to establish a domestic partnership, and I now inform the Office of Human
Resources that:

_____________________________ is no longer my domestic partner as of _________________
(Name of former Domestic Partner – Print)

(Date of Termination)

I understand that the domestic partner identified above is no longer eligible for the following

• Group Health Benefits (medical, dental, and voluntary vision care plans)
• Group Term Life Insurance
• Group Accidental Death and Dismemberment Insurance

I certify that in addition to this Statement, I am submitting to the Office of Human Resources the
necessary forms for the purpose of canceling any benefits plan coverage(s) in which my former
domestic partner was enrolled.

I also certify that I will provide my former domestic partner within ten (10) days of completing this
Statement with a copy of this Statement at the following address (please print):

Former Domestic Partner’s Name

Street Address

City State Zip Code

(The Office of Human Resources will use this address to mail Health Plan Continuation of Coverage
information to your former domestic partner, unless another address is provided.)

I understand that another Affidavit of Domestic Partnership may not be filed to establish a new domestic
partnership until twelve (12) months after this domestic partnership has been terminated as identified


Rev. 9-29-08