Domestic Partnership

University of Wisconsin-La Crosse

We,                                                                        and ___________________________________
                 (name of student, please print)                             (name of domestic partner, please print)

certify that:

1. We are each other's sole domestic partner, responsible for each other's common welfare:
2. We are not married to anyone;
3. We are at least 18 years of age or older;
4. We are not related by blood to a degree that would bar marriage in the state of Wisconsin;
5. That the following conditions exist for our relationship:
        A. This relationship has been in existence for a period of at least 12 consecutive months.
        B. We currently share the same residence and intend to do so indefinitely.
        C. We have at least two of the following (and can provide documentation if requested):
                1. Domestic partnership agreement
                2. Joint mortgage, lease, or title
                3. Designation of domestic partner as beneficiary for life insurance or retirement contract
                4. Durable property or health care powers of attorney
                5. Joint ownership of motor vehicle, joint checking account, or joint credit account
6. We agree to notify the Student Life Office of any change in the circumstances that have been attested to in the documentation qualifying a person for coverage as a Domestic Partner.
7. We understand that any false or misleading statements in order to receive benefits for which domestic partners do not qualify may subject the student to disciplinary action.
8. We understand that either member of a domestic partnership may file a statement with the Student Life Office within 30 days indicating the relationship has ended. A copy of the termination will be mailed to the other partner unless both have signed the termination statement.
9. We understand that the student must wait a period of at least 12 months before being eligible to designate a new Domestic Partner.
10. We affirm, under penalty of perjury, that the ascertainments in this affidavit are true to the best of our knowledge.

    (signature of student)                                                       (signature of domestic partner)

    (student ID number)                                                          (domestic partner ID/SSN)

    (date)                                                                              (date)

    (student date of birth)                                                        (domestic partner date of birth)

Please bring signed and dated form to the Student Life Office, 149 Graff Main Hall.