Seattle Fire Fighters Union Local 27 Welfare Trust

Sponsor of

FIRE FIGHTERS UNION HEALTH BENEFITS PROGRAM

Administered by Benefit Solutions, Inc.

• P.O. Box 6 Mukilteo, WA 98275
• phone: 206-859-2600 toll free: 800-203-0544 fax: 206-859-2635

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AFFIDAVIT OF DOMESTlC PARTNERSHIP

I______________________, certify that Name of Employee (Print)

I, and _________________are domestic partners, and we:

                    Name of Domestic Partner (Print)

1. Share the same regular and permanent residence; and

2. Have a close, personal relationship; and

3. Are jointly responsible for "basic living expenses", as defined below; and

4. Are not married to anyone: and

5. Are each eighteen (18) years of age or older: and

6. Are not related by blood closer than would bar marriage in the State of __________________; and

7. Were mentally competent to consent to contract when our domestic partnership began; and

8. Are each other's sole domestic partner and are responsible for each other's

common welfare.

"Basic living expenses" means the cost of basic food, shelter, and any other expenses of a Domestic Partner which are paid at least in part by a program or benefit for which the partner qualified because of the Domestic Partnership. The individuals need not contribute equally or jointly to the cost of these expenses as long as they agree that both are responsible for the cost.

SECTION II

A. I understand that this affidavit shall be terminated upon the death of my spouse/domestic partner or by a change of my circumstance attested to in this affidavit.

I agree to notify my payroll/personnel representative if there is any change of

circumstances attested to in this affidavit with thirty (30) days of change by filing a Statement of Termination of Marriage/Domestic Partnership.

B. After such termination, I understand that another Affidavit of Marriage/Domestic Partnership cannot be filed until ninety (90) days after a Statement of Termination of Marriage/Domestic Partnership has been filed with my payroll/personnel representative, unless such termination is due to the death of my spouse/domestic partner or dissolution of my marriage.

SECTION Ill

We understand that this information will be held confidential and will be subject to disclosure only upon our express written authorization or if otherwise required by law.

We understand that this declaration of responsibility for our common welfare may have legal implications under state law.

We understand that a civil action may be brought against us for any losses, including reasonable attorney's fees, because of a false statement contained in this affidavit of Marriage/Domestic Partnership.

We also certify under penalty of perjury, under laws of the State of __________________________, that the foregoing is true and correct.

I, the undersigned employee, understand that willful falsification of information on this affidavit may lead to disciplinary action, up to and including discharge from employment.

Signature of Employee_____________________________________________________________________

Address______________________________________________________________________

Signature of

Spouse/Domestic Partner_______________________________________________________

Address______________________________________________________________________