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Employee Information |
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Name: |
Last First Middle |
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Social Security #: - - Date of Birth: / / Gender: Male Female |
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Address: |
Street |
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City Zip |
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Domestic Partner Information |
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Name: |
Last First Middle |
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Social Security #: - - Date of Birth: / / Gender: Male Female |
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Address: |
Street |
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City Zip |
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Domestic Partner's Dependent Child(ren) Information |
(List only the domestic partnerÕs unmarried biological or adopted child(ren) who were listed on the original Affidavit of Same-Sex Domestic Partnership.) |
Dependent Child Name (Last, First, Middle) |
Social Security Number |
Date of Birth |
RC* |
Married |
Full-time Student |
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DS
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Y
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Y
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DS
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Y
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Y
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*RC (Relationship Code): DS = biological or adopted son of domestic partner DD = biological or adopted daughter of domestic partner |
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CERTIFICATION
This certifies that as of _____________________ (date) my domestic partnership with the above person has terminated. I understand that to register another domestic partnership I must wait six months from the date listed above.
I further understand that the domestic partnerÕs eligibility for Indiana University sponsored benefits ends on the date the domestic partnership terminates. Failure to notify the university within 60 days of the termination date may result in liability for benefits paid for ineligible individuals, and disciplinary action (including cancellation of the employeeÕs health plan coverage or termination of employment). In the case of a domestic partner or associated child covered under an Indiana University sponsored health care plan, failure to provide timely notice to the university jeopardizes COBRA health care continuation coverage. COBRA coverage must be elected within 60 days of the termination of the domestic partnerÕs health care coverage.
I certify that the information supplied on this form is true and complete, and I understand that any false information or statements made on this form will be grounds for Indiana University to void my coverage and/or terminate my employment.
Employee Signature_____________________________________________ Date__________________________
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