CHABOTLAS POSITAS COMMUNITY COLLEGE DISTRICT

Office of Human Resources

Domestic Partnership: Affidavit

IDECLAREUNDERPENALTYOFPERJURYUNDERTHELAWSOFTHESTATE
OF CALIFORNIATHATTHESTATEMENTSBELOWARETRUEANDCORRECT.

1. Wehaveanintimate,committedrelationshipofmutualcaring
2. Welivetogether(seedefinitiononthenextpage)
3. Weagreetoberesponsibleforeachother'sbasiclivingexpenses(seedefinitiononthenext
page)duringourdomesticpartnershipwealsoagreethatanyonewhoisowedthese
expensescancollectfromeitherofus
4. Weareboth18orolder
5. Neitherofusismarried
6. Neitherofusisrelatedtotheother
7. Neitherofushasadifferentdomesticpartnernow
8. Neitherofushashadadifferentpartnerinthelastsixmonths(thislastcondition
doesnotapplyifyouhadapartnerwhodiedifyoudid,crossthisout).

WedeclareunderpenaltyofperjuryunderthelawsoftheStateofCaliforniathatthe
statementsabovearetrueandcorrect.
(PleasePrint)

Date:____/____/____

EmployeesName:_______________________________________________________
(Last)(First)(Middle)

DomesticPartnersName:_________________________________________________
(Last)(First)(Middle)

SharedResidenceAddress:____________________________________________________________
(Street&Number)(City)(State/Zip)

Employee'sSignature:________________________________Signedon:____/____/____

DomesticPartnersSignature:__________________________Signedon:____/____/____

Updated06/20083/21/13
P:/FORMS/Faculty200708/DomesticPartnershipAffidavitUpdtd.doc
PageTwo
DomesticPartnership:Affidavit

DEFINITIONS:

"Livetogether"meansthatthedomesticpartnersshareaplacetolive.

"Basicliving expenses" means the cost of basic food and shelter. It also includes
any other expense, which ispaid by a benefit either partner receives becauseof
the partnership. For example, domestic partners who receive health insurance
coveragearemutuallyresponsibleformedicalbills,whichtheinsurancedoesnot
pay. It is not necessary to actually split basic living expenses to be domestic
partners.Thepartnersjusthavetoagreetoprovidethesethingsfortheirpartnerif
thepartnerisunabletoprovideforhimorherself.

THELASTSTEP:

Tocompletesettingupadomesticpartnership,youmustsignthisforminfront
ofaNotaryPublic,havetheNotaryfillinthenotarizationatthebottomofthispage,
andsubmittheAffidavittotheOfficeofHumanResources,7600DublinBoulevard,
3rd Floor,DublinCA94568.

NOTARIZATION:

Stateof________________________________,Countyof__________________
on____/____/____beforeme,__________________________________________
Date NameandTitleofOfficer(e.g.,"JaneDoe,NotaryPublic")
Personallyappeared:

________________________________________________________________
Name(s)ofSigners

Whoprovedtomeonthebasisof satisfactoryevidencetobetheperson(s)whose
name(s)is/aresubscribedtothewithininstrumentandacknowledgedtomethat
he/she/theyexecutedthesameinhis/her/theirauthorizedcapacity(ies),andthatby
his/her/theirsignature(s)ontheinstrumenttheperson(s),ortheentryuponbehalfof
whichtheperson(s)acted,executedtheinstrument.

IcertifyunderPENALTYOFPERJURYunderthelawsoftheStateofCalifornia
thattheforegoingparagraphistrueandcorrect.

WITNESSmyhandandofficialseal,

SignatureofNotaryPublic _____________________________________________

Reference: Article20A.3,20A.3bFacultyCollectiveBargainingAgreement

Updated06/20083/21/13
P:/FORMS/Faculty200708/DomesticPartnershipAffidavitUpdtd.doc