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deemed conclusive evidence of the termination of the domestic partnership status for <br />purposes of this benefit. In the event that more than one such Declaration of <br />Termination of Domestic Partnership is provided with conflicting dates of termination <br />of the domestic partnership, the employer shall rely on the document with the earlier <br />date. <br />III. Acknowledgments <br />A. The above named understand that a civil action may be brought against one or both <br />for any losses (including attorney's fees and costs) due to any false statement <br />contained in this Declaration or for failure to notify the employer of changed <br />circumstances as required in Section II, above. The undersigned employee filrther <br />understands that falsification of information in this Declaration or failure to notify the <br />emplcyer of changed circumstances pursuant to Section II, above, may lead to <br />disciplinary action, including discharge from employment, <br />B. The above named have provided information in this Declaration for use by the <br />employer for the sole purpose of determining our eligibility for certain health <br />insurance benefits. We understand and agree that the employer is not legally <br />required to extend such benefits to domestic partners and that my employer may <br />change or terminate these benefits in its discretion without consent of any employee <br />or group of employees. <br />C. The above named understand that the information provided in this Declaration will be <br />treated as confidential but will be subject to disclosure: <br />t, Upon the express written authorization of the undersigned or <br />2. If otherwise required by law, <br />D, The above named understand that this Declaration may have legal implication <br />relating, for example, to our ownership of property or to taxability of benefits provided, <br />We understand that before signing this Declaration we should seek competent legal <br />and tax advice concerning such matters. We acknowledge that the employer has <br />provided us with no advice in this regard, <br />We affirm, under penalty of perjury, that the statements in this Declaration are trfae and correct. <br />Employee <br />Printed name: <br />Domestic Partner <br />Printed name: <br />Date of birth <br />/ /_ <br />Date <br />Date of birth <br />/ / <br />Date <br />NCACC Group Benefits Pool Page 2 of 2 <br />Declaration of Domestic Partnership <br />Ado ted b the Board of Trustees Janua 2.2001 <br />