Research Corporation of the University of Hawaiʻi

Research Corporation
of the University of Hawai‘i
Human Resources Department
Declaration of Domestic Partnership
I. DECLARATION
We, ______________________________, (Employee) and, _____________________________, (Domestic Partner), each declare that we established a domestic relationship effective ____________________________ (date) and certify every one of the following criteria:
II. ELIGIBILITY CRITERIA
1. The employee and the domestic partner are in an exclusive spouse-like relationship and intend to remain in a domestic partnership with each other indefinitely.
2. The employee and the domestic partner have a common residence and intend to reside together indefinitely.
3. The employee and the domestic partner are and agree to be jointly and severally responsible for each other’s basic living expenses incurred in the domestic partnership, such as food, shelter, and medical care.
4. Neithertheemployeenorthedomesticpartnerismarriedoramemberofanotherdomestic partnership.
5. The employee and the domestic partner are not related by blood in a way that would prevent them from being married to each other in the State of Hawaii.
6. The employee and the domestic partner are both at least 18 years of age and mentally competent to contract.
7. The consent to the domestic partnership by the employee or the domestic partner has not been obtained by force, duress, or fraud.
8. The employee and the domestic partner hereby agree to sign and file with the RCUH any and all declarations of domestic partnership and/or verifications of eligibility as the RCUH Board may from time to time prescribe.
III. CHANGE IN DOMESTIC PARTNERSHIP
1. We understand that we have an obligation to notify the RCUH by filing a Declaration of Termination of Domestic Partnership if there is any change in our domestic partnership status as a result of: (a) any of the criteria in Section II of this Declaration ceasing to be true; (b) the death of the domestic partner; or (c) the termination or dissolution of our domestic partnership. We will notify the RCUH as soon as possible of such change. The form for making this notification is available from the RCUH Human Resources Department.
2. We understand that coverage of the domestic partner (obtained as a result of completion of this Declaration) will be terminated upon the RCUH’s receipt of a notice of change in our domestic partnership or upon the RCUH’s receipt of any other proper notification requesting termination of such coverage.
IV. ACKNOWLEDGMENTS
1. We understand that a civil action may be brought against one or both of us for any losses (as well as attorney’s fees and costs) due to any false statement contained in this Declaration or for failure to notify the RCUH of changed circumstances as required in Section III above. I, the undersigned employee, further understand that falsification of information in this Declaration, or failure to notify the RCUH, of changed circumstances pursuant to Section III above, may lead to disciplinary actions against me, up to and including discharge from employment.
2. We have provided the information in this Declaration for use by the RCUH for the sole purpose of determining our eligibility for certain domestic partner benefits. We understand and agree

RE: Declaration of domestic partnership Page 2 of 2
that the RCUH is not legally required to extend any such benefits. We understand that the information provided in this Declaration will be treated as confidential by the RCUH but will be subject to disclosure; (a) upon the express written authorization of the undersigned employee, (b) upon request of the insurer or plan administrator, or (c) if otherwise required by law.
3. We understand that this Declaration may have legal implications relating, for example, to our ownership of property, qualifications required to pay premiums with pretax funds, or to taxability of benefits provided, and that before signing this Declaration we should seek competent legal advice concerning such matters.
_________________________________________________________________
We affirm, under penalty of perjury, that the statements in this Declaration are true and correct.
___________________________________ Employee’s Signature
___________________________________ Print Employee’s Name
___________________________________ Employee’s SS#
Employee/Domestic Partner Address:
Subscribed and sworn to before me
This _____ day of _____________, 20 ___.
___________________________________ Signature of Notary Public
___________________________________ Notary Public – State of Hawaii (print name)
My commission expires: _______________
Provide Notary Seal below:
_____________________________________ Domestic Partner’s Signature
_____________________________________ Print Domestic Partner’s Name
_____________________________________ Domestic Partner’s SS#
___________________________________________
___________________________________________
___________________________________________
Subscribed and sworn to before me
This _____ day of _____________, 20 ___.
___________________________________ Signature of Notary Public
___________________________________ Notary Public – State of Hawaii (print name)
My commission expires: _______________
Provide Notary Seal below:
RCUH Form B-14
Created 03/10/2011, Rev. 06/17/2014, 03/30/2016