L G B T   C a m p u s   O r g a n i z i n g
University of Minnesota
Employee/Student__________________  Social Security Number___ ___ ___ 
I.D. Number__________________
Partner _____________________
Partner s Dependent Children
Names Birthdates
____________________ ________________
____________________ ________________
____________________ ________________
We the undersigned declare that we are domestic partners, as established by the following criteria:
1) We are engaged in a long term committed relationship and intend to remain together indefinitely;
2) We are not married and neither of us has any other domestic partners;
3) We are the same gender and for this reason we are unable to marry each other under Minnesota law;
4) We are at least 18 years of age and have the capacity to enter into a contract;
5) We share a residence;
6) We are jointly responsible to each other for the necessities of life.  If asked, we could produce docu 
mentation of at least three of the following items as evidence of our joint responsibility:
a. Joint mortgage or joint tenancy on a residential lease;
b. Joint bank account;
c. Joint liabilities, e.g., credit cards or car loans;
d. Joint ownership of significant property, e.g., cars; 
e. durable property or health care powers of attorney; 
f. Naming each other as primary beneficiary in wills, life insurance policies or retirement annu 
g. Written agreements or contracts regarding our relationship showing mutual support obligations
or joint ownership of assets acquired during the relationship;
7) We are not related by blood closer than permitted under Minnesota marriage laws; and
8) The children identified above qualify as dependents under IRS regulations.
We agree to notify the University of Minnesota within thirty (30) days of the termination of our domes 
tic partnership under the above criteria by filing a Notice of Termination of Domestic Partnership with
___________________.  We understand that an individual cannot register another domestic partner for
six months following the filing of a Notice of Termination of a Domestic Partnership.
We understand that a false declaration of a Domestic partnership or failure to inform the University of
Minnesota of the termination of a domestic partnership in a timely fashion may result in disciplinary
action of an employee or student up to and including termination or dismissal.  We agree that in the event
of a false declaration, the University of Minnesota may recover damages for all losses and reasonable
attorneys  fees incurred by the University to recover such damages.
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A p p e n d i x   D :   S a m p l e   A f f i d a v i t


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