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Note: To qualify for pomestic Partner coverage, the employee and his or her pomestic Partner must meet all of the <br />following criteria and must sign the North Carolina Association of County CommissionersT"' Risk Management <br />Poo1T"'s Declaration of Domestic Partner status attesting that they are: <br />a. At least 18 years old and mentally competent to consent to a civil contract, <br />b. Not acting under force or duress, <br />c. Not legally married to any other person and not engaged in another domestic partner relationship, <br />d. Not related by blood, <br />e. Engaged in an exclusive, committed relationship that has existed for at least 12 consecutive months, <br />f. Currently reside together and intend to do so permanently, <br />g. Responsible for each otherT"ss common welfare and either: <br />- Are jointly responsible for their assets and debts as provided by applicable law, or <br />- I-Iave executed a written agreement or civil contract which defines their domestic partner <br />relationship and their liabilities with respect to their assets and debts. <br />- Not Medicare eligible. <br />Customer Service Toll-Free Number: 800-524-0149 <br />www. DeltaDentalNC.com <br />October 25, 2011 <br />