Declaration of Domestic Partnership: 

FEHB and FEDVIP

DOMESTIC PARTNER means a person in a domestic partnership with an employee or annuitant 

of the same sex.

DOMESTIC PARTNERSHIP means a committed relationship between two adults, of the same sex, that

meets all of the requirements below. 

We attest and declare that the following statements (A through H) are true and correct:

A. We are each other’s sole domestic partner and intend to remain so indefinitely;

B. We have a common residence and intend to continue the arrangement indefinitely;

C. We are at least 18 years of age and mentally competent to consent to contract;

D.We share responsibility for a significant measure of each other’s financial obligations;

E. Neither of us is married (legally or by common law) to, legally separated from, or joined in a civil 

union with anyone else; 

F. Neither of us is a domestic partner of anyone else;

G.We are not related in a way that, if we were of opposite sex, would prohibit legal marriage as of the day before 

the current open season, or; 

H. Either (select applicable situation): 

 □For Stepchildren to be Covered Effective in January 2014, or Other Open Season Enrollments or 

Changes: We would marry but for the state of our residence [____] to permit same-sex marriage as of the 

day before the current open season, or; STATE

 □For Stepchildren to be Covered as a Qualifying Life Event: We would marry but for the state of our 

residence [____] to permit same-sex marriage as of the date I am signing this declaration.

 STATE

We also agree to, and understand that:

1. We must inform the appropriate employing agency or retirement system of the dissolution of this 

domestic partnership (which includes the death of either partner) not later than 30 days after we 

no longer meet the definition of Domestic Partnership;

2. Either domestic partner may inform the employing agency or retirement system of the dissolution 

of the domestic partnership; 

3. A child's continued eligibility for FEHB/FEDVIP coverage as a stepchild who is the child of a 

same-sex domestic partner must be determined on an annual basis at Open Season. We 

understand that, should the laws in our state of residence change prior to the next Open 

Season to permit same-sex couples to marry, or if we move to a state that permits same-sex 

marriage, and we choose not marry, we will inform our employing office or retirement system 

that our child's coverage must be terminated for the following plan year;

and,

4. Willful falsification of information within this document may lead to disciplinary action, loss of 

insurance coverage, and/or the recovery of the cost of benefits received related to such falsification.

PRINTED Name of Employee/Annuitant

Last name First name M.I.

Signature of Employee/Annuitant

Date Signed / /

Social Security number or Other Employee Identifier Civil Service Retirement number (CSA or CSF), if applicable
PRINTED Name of Domestic Partner

Last name First name M.I.

Signature of Domestic Partner

Date Signed / /

Date Domestic Partnership was formed / /

To complete the registration of this Domestic Partnership, you must file this form with your current 

employing agency or retirement system. Please keep a copy for your own records.

AGENCY/RETIREMENT SYSTEM RECEIPT

Name and signature of agency/retirement system official and date or official date stamp or other means by 

which the agency or retirement system indicates official receipt:

Name 

Signature Date / /

December 2013