Restaurant Domestic Partnership Affidavit Template

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The main purpose of a domestic partnership is to determine eligibility for domestic partner benefits. Create a legally compliant document with our Restaurant Domestic Partnership Affidavit template. Our affidavit will gauge if requirements are met regarding eligibility. When you utilize this template, you don’t have to start from scratch with this since it’s content-ready and is easily adjustable to fit your business for added convenience. This professional looking template isn’t just limited to a computer. You can view and edit it on your tablet and phone as well. It’s everything you need in a template. Don’t pass up this opportunity, download it now!

AFFIDAVIT OF DOMESTIC PARTNERSHIP

Employee Information

Employee Name: (Last Name, First Name, Middle Initial)
Employee Number:
Gender:
Date of Birth:
Position:

[ROLE OR POSITION]
Address:

[ADDRESS LINE 1]
[ADDRESS LINE 2]
Zip Code:

[CODE]

Domestic Partner Information

Domestic Partner Name: (Last Name, First Name, Middle Initial)
Social Security Number:
Gender:
Date of Birth:
Position:

[ROLE OR POSITION]
Address:

[ADDRESS LINE 1]
[ADDRESS LINE 2]
Zip Code:

[CODE]

We do hereby certify ourselves as domestic partners and declare the following:

• We are both 18 years of age or older and mentally competent to execute a contract
• Neither of us is legally married to a third party
• We share a permanent residence
• Neither of us is a party to any other domestic partnership or has been a party to another domestic partnership in the last six months and intend to stay in the aforementioned relationship indefinitely
• We are not related to each other by blood in a way that may bar marriage in the state of [NAME OF STATE]
• We are engaged in a close and personal relationship and have been living together continuously for at least one year
• We understand that this Domestic Partnership Affidavit creates a continuous partnership duration until either party files for termination of such partnership or upon death or marriage by either one of us
• As proof of our financial interdependence, we have submitted the following evidence documents attached herewith: [INSERT ANY TWO OF THE FOLLOWING]

JOINT BANK ACCOUNT
Bank statement with both names
Passbook with both names
Bank check with both names
JOINT CREDIT CARD
Credit statement with both names
JOINT OBLIGORS FOR A LOAN
Loan document with both names
JOINT OWNERSHIP FOR RESIDENCE
Deed with both names
Property Tax Document with both names
Mortgage Agreement showing both names
JOINT TENANTS OF A LEASE
Lease document with both names
TAX RETURNS
LIFE INSURANCE
Insurance copy showing the principal naming the domestic partner as the beneficiary
JOINT CUSTODY OF A CHILD
JOINT OWNERSHIP OF A VEHICLE
Title showing both names
JOINT WILLS
Copy of will naming the other partner as beneficiary or executor
POWER OF ATTORNEY
Copy of power of attorney naming the other partner
DOMESTIC PARTNERSHIP REGISTRATION
Copy of the registration filed and recognized by other states
RETIREMENT BENEFITS
Copy of document designating the other as beneficiary
JOINT INVESTMENT
Investment securities with both names
Statement of mutual fund showing both names
DAYCARE
Joint childcare responsibility showing as guardian for school documents

Acknowledgements:

• We have read and understood the eligibility requirements and tax information as required for by this document
• The employee is responsible for informing the restaurant of being unqualified for domestic partnership benefits by submitting a Termination of Domestic Partnership Status form to management within [NUMBER] days from last date of eligibility taking into account the last day of eligibility is the last day of the month of the termination of the domestic partnership.
• Both parties waive, release, and indemnify [SPECIFY YOUR RESTAURANT NAME], its officers and representatives from any and all claims arising out of the benefits given from this domestic partnership affidavit.
• The cost for the provision of domestic partner benefits and employee payroll contribution shall be considered as taxable income to the employee unless the domestic partner is a qualified tax dependent of the employee.
• [SPECIFY YOUR RESTAURANT NAME] reserves the right to change, amend or terminate this affidavit via a board resolution or a written approval by an authorized officer.

We hereby attest to the correctness of the aforementioned information and that falsely declaring a domestic partnership or failure to timely provide notice of termination of such partnership with the [SPECIFY YOUR RESTAURANT NAME] shall constitute fraud which may be grounds for filing damages as a result of such false declaration including but not limited to benefits paid on behalf of the employee, the domestic partner, and other legal fees incurred.

Both parties acknowledge and signed below on this [NUMBER] day of [MONTH] [YEAR].

[EMPLOYEE NAME AND SIGNATURE]

[DATE SIGNED]

[DOMESTIC PARTNER NAME AND SIGNATURE]

[DATE SIGNED]

Notarized:

State of [NAME OF STATE]
Sworn before me this [NUMBER] day of [MONTH] [YEAR]

[NAME OF NOTARY PUBLIC REPRESENTATIVE] [NOTARY PUBLIC NUMBER]
[EXPIRY DATE]