University of Wisconsin-La Crosse
STUDENT AFFIDAVIT OF DOMESTIC PARTNERSHIP
We, _________________________________ and _____________________________
(name of Student, please print)
(name of Domestic Partner, please print)
Certify that:
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10.
We are each other’s sole domestic partner, responsible for each other’s common welfare;
We are not in a marriage legally recognized by the State of Wisconsin;
We are at least 18 years of age or older;
We are not related by blood to a degree that would bar marriage in the state of Wisconsin;
That the following conditions exist for our relationship:
a. This relationship has been in existence for a period of at least 12 consecutive months.
b. We currently share the same residence and intend to do so indefinitely.
c. We have at least two of the following (and can provide documentation if requested):
i. Domestic partnership agreement;
ii. Joint mortgage, lease, or title;
iii. Designation of domestic partner as beneficiary for life insurance or retirement
contract;
iv. Durable property or health care powers of attorney;
v. Joint ownership of motor vehicle, joint checking account, or joint credit account.
We agree to notify Student Life of any change in the circumstances that have been attested to in
the documentation qualifying a person for coverage as a Domestic Partner;
We understand that any false or misleading statements in order to receive benefits for which
domestic partners do not qualify may subject the student to disciplinary action;
We understand that either member of a domestic partnership may file a statement with Student
Life within 30 days indicating the relationship has ended. A copy of the termination will be
mailed to the other partner unless both have signed the termination statement;
We understand that the student must wait a period of at least 12 months before being eligible
to designate a new Domestic Partner;
We affirm, under penalty of perjury, that the ascertainments in this affidavit are true to the best
of our knowledge.
_____________________________
_____________________________
(Signature of Student)
(Signature of Domestic Partner)
_____________________________
_____________________________
_____________________________
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(Student ID number)
(Date)
(Student date of birth)
(Domestic Partner Driver or State ID number)
(Date)
(Domestic Partner date of birth)
Please bring signed and dated form to Student Life, 149 Graff Main Hall.