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North Carolina Association of County Commissioners <br />Risk Management Pools <br />8 <br />Attachment 2 <br />BOARD OF TRUSTEES POLICY STATEMENT <br />Declaration of Domestic Partner Status <br />I. 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 />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 />D, 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 />1. 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 defnes our <br />domestic partnership and our liabilities with respect to our assets and debts, <br />(Orange County Administrative Note: The Orange County Personnel Department will review <br />the documentation provided by the employee to determine whether or not it provides <br />sufficient documentation of an eligible domestic partner relationship. If not, Personnel will <br />ask the employee to provide additional documentation as necessary.) <br />II. 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 or <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 />deemed conclusive evidence of the termination of the domestic partnership status far <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 />