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North Carolina Association of County Commissioners <br />F2isk anagement Pools Attachment Z <br />BOARD OF TRUSTEES POLICY STATEMENT <br />Declaration of Domestic Partner Status <br />Declaration <br />We, <br />(employee), and <br />(Domestic Partner) <br />each certify and declare that we are each other's sole Domestic Partners as set out below: <br />(Domestic Partner), each certify and declare that we are each other's sole Domestic Partners <br />as set out below, <br />A, We are both at least eighteen (18) years old and mentally competent to consent to a <br />civil contract; and <br />B, We are not acting under force or duress; and <br />C. Neither of us is married to or legally separated from any other person and neither of <br />us is engaged in another domestic partnership; and <br />U. We are not related by blood; and <br />E. We have been engaged in a committed relationship of mutual caring and support for <br />at least 12 consecutive months; and <br />F. We currently reside together and intend to do so permanently; and <br />G. We are jointly responsible for each other's common welfare; and either: <br />We are jointly responsible for our assets and debts as provided by applicable <br />law; or <br />2. We have executed a written agreement or civil contract, which defines our <br />domestic partnership and cur liabilities with respect tc our assets and debts, <br />Termination of Domestic Partnership <br />A, The above named employee has an obligation to ensure that the employer receives a <br />written notice of Declaration of Termination of Domestic Partnership if there is any <br />change in the domestic partnership status that makes this Declaration invalid ar <br />erroneous. Notice shall be provided by the employee to the Human Resources <br />Department within thirty-one (31) days of such change, <br />B, The above named understand that termination of benefit coverage obtained as a <br />result of this Declaration will be effective on the last day of the month during which <br />the domestic partnership ends or at such time as coverage terminates in accordance <br />with the terms and conditions of applicable policies, Receipt by the employer of a <br />Declaration of Termination of Domestic Partnership from the employee shall be <br />NCACC Group Benefits Pool Page 1 of 2 <br />Declaration of Domestic Partnership <br />Ado ted b the Board of Trustees Janua 2, 2001 <br />