> ![](media/image1.png){width="2.7506944444444446in"
> height="0.42986111111111114in"}
>
> Operated for the U.S. Department of Energy by
>
> **Sandia Corporation**
>
> **Sandia National Laboratories** Albuquerque, NM 87185-1022
>
> **Benefits Department, 3332** Phone: (505) 845-2363
>
> **PO Box 5800, MS 1022** Fax: (505) 844-0662
>
> **Albuquerque, New Mexico 87185-1022**
>
> **505 845-2363**
>
> <http://www-irn.sandia.gov/hr/benefits/Health/dp/>
>
> **Domestic Partner Affidavit**
>
> *To be completed by the employee and submitted to the Sandia Benefits
> Customer Service Center at the address above. Please keep a copy for
> your records.*

*Sworn Affidavit*

  ----- ------------------------------ ----- --------------------------------
  We,   **     **                      and   **     **

        (Employee -- PRINT NAME)             (Domestic Partner -- PRINT NAME)
  ----- ------------------------------ ----- --------------------------------

> do hereby certify and declare under the penalties of perjury that we
> are same-gender domestic partners in accordance with the following
> criteria. We further certify that any dependent children of the
> domestic partner we elect to cover are eligible under the rules of the
> Sandia benefits program.

*Domestic Partner Criteria\
*

-   We are each other's sole domestic partner and intend to remain so
    permanently and indefinitely.

-   We are both the same gender.

-   Neither of us is currently married to another person (even if
    legally separated).

-   We are not related by blood (e.g., brothers, sisters, parents,
    children, cousins, nieces, uncles).

-   We are at least 18 years of age and mentally competent to make this
    sworn affidavit.

-   We have continuously resided together with no other domestic partner
    in the same residence for six months or more.

-   We share a committed and mutually dependent exclusive relationship
    with each other that is similar to that of a married couple, but we
    cannot legally marry in the state in which we reside.

-   We recognize that domestic partner benefits are not provided under
    all Sandia benefits and insurance plans, and understand that we must
    meet the eligibility requirements of the particular benefits plan(s)
    we are requesting coverage for as domestic partners.

-   Our domestic partner relationship does not violate the law in our
    state of residency.

-   The domestic partner of the employee is a citizen of the United
    States or, in the alternative, satisfies the residency requirements
    of the United States.

    *Change in Domestic Partnership*

> We agree to provide notification when and if there is any change in
> our status as domestic partners as described under oath in this
> Affidavit that would make the non-employee domestic partner and/or any
> of his/her dependent children ineligible for the Sandia Laboratories
> benefits program (for example, due to the death of the non-employee
> domestic partner, a change in joint-residence, termination of the
> domestic partner relationship, emancipation of dependent children,
> etc., or any other change which then make it impossible for us to
> truthfully complete and execute this same sworn affidavit).
>
> We will provide notification within 31 days of any such change in the
> status of our domestic relationship. Coverage under the Sandia
> Laboratories benefits program will be terminated as of the date we no
> longer meet the criteria listed above.

*Acknowledgements***\
\
*We understand that any person/employer/insurer/claims administrator
(including Sandia and its third party plan administrators and HMOs) who
suffers any loss due to any false statement contained in this Affidavit
may bring civil action against either or both of us to recover their
losses, including reasonable attorney's fees.***

> We have provided the information in this Affidavit for the sole
> purpose of enabling Sandia to determine our eligibility for domestic
> partner benefits. We understand that this information will be held
> confidential from disclosure outside Sandia, treated in accordance
> with all applicable federal and state regulations and will be subject
> to disclosure outside Sandia only upon our express written
> authorization, pursuant to a court order or legitimate governmental
> demand for such information from the Internal Revenue Service or a
> state or federal labor law enforcement agency, or if there is another
> compelling and legitimate business need to provide access to the
> information.
>
> We understand that this Affidavit may have intended and unintended
> legal implications, not all of which may be known by us today,
> relating, for example, to our ownership or disposition of property or
> to the taxability of benefits provided by Sandia, and that before
> signing this Affidavit, we should seek competent legal and accounting
> advice from our own attorney and CPAs concerning such matters.
>
> We each declare, under penalties of perjury, that the statements in
> this Affidavit are true to the best of our knowledge. We understand
> that this form is not an application for benefits coverage and that
> the purpose for this form is to establish the eligibility of person
> named herein as a domestic partner for the coverage provided under the
> Sandia Laboratories benefits program.
>
> Please complete this form and return it along with the required
> documentation to the following address:
>
> **Sandia National Laboratories**
>
> **Benefits Department, 3332**
>
> **PO Box 5800, MS1022**
>
> **Albuquerque, New Mexico 87185-1022**
>
> Please keep a copy of this completed form for your records.

+------------------------------+---+-------------------------------------+
|                              |   | > City of                           |
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|                              |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|                              |   | > County of                         |
|                              |   | > \_\                               |
|                              |   | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                              |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|                              |   | > Sworn to before me at             |
|                              |   | > \_\_\_\_\_\_                      |
|                              |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, |
|                              |   | > this \_\_\_\_\_\_\_\_\_\_\_ day   |
|                              |   | > of                                |
|                              |   | > \_\_\_\_                          |
|                              |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, |
|                              |   | > 20\_\_\_\_.\                      |
|                              |   | > Notary                            |
|                              |   | > Public\_\_\                       |
|                              |   | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                              |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|                              |   | > My Commission expires             |
|                              |   | > \_\_                              |
|                              |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, |
|                              |   | > 20\_\_\_\_\_.                     |
+------------------------------+---+-------------------------------------+
| > Signature of Employee      |   |                                     |
| >                            |   |                                     |
| > **    -    -     **        |   |                                     |
+------------------------------+---+-------------------------------------+
| > Employee Social Security   |   |                                     |
| > Number                     |   |                                     |
| >                            |   |                                     |
| > **     **                  |   |                                     |
+------------------------------+---+-------------------------------------+
| > Partners' Street Address   |   |                                     |
| >                            |   |                                     |
| > **     **                  |   |                                     |
+------------------------------+---+-------------------------------------+
| > City, State, Zip           |   |                                     |
+------------------------------+---+-------------------------------------+

+------------------------------+---+-------------------------------------+
|                              |   | > City of                           |
|                              |   | > \_\_\_\_\_\                       |
|                              |   | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                              |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|                              |   | > County of                         |
|                              |   | > \_\                               |
|                              |   | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                              |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|                              |   | > Sworn to before me at             |
|                              |   | > \_\_\_\_\_\_                      |
|                              |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, |
|                              |   | > this \_\_\_\_\_\_\_\_\_\_\_ day   |
|                              |   | > of                                |
|                              |   | > \_\_\_\_                          |
|                              |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, |
|                              |   | > 20\_\_\_\_.\                      |
|                              |   | > Notary                            |
|                              |   | > Public\_\_\                       |
|                              |   | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                              |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|                              |   | > My Commission expires             |
|                              |   | > \_\_                              |
|                              |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, |
|                              |   | > 20\_\_\_\_\_.                     |
+------------------------------+---+-------------------------------------+
| > Signature of Domestic      |   |                                     |
| > Partner                    |   |                                     |
| >                            |   |                                     |
| > **   ** - **  ** -         |   |                                     |
| > **    **                   |   |                                     |
+------------------------------+---+-------------------------------------+
| > Domestic Partner Social    |   |                                     |
| > Security Number            |   |                                     |
| >                            |   |                                     |
| > **     **                  |   |                                     |
+------------------------------+---+-------------------------------------+
| > Domestic Partner Date of   |   |                                     |
| > Birth (m/d/yy)             |   |                                     |
+------------------------------+---+-------------------------------------+
|                              |   |                                     |
+------------------------------+---+-------------------------------------+