Instructions:
In order to enroll your Domestic Partner for medical benefits, you and your Domestic Partner must sign this Affidavit of Domestic Partnership. Please carefully read this Affidavit and the information below.
Both you and your Domestic Partner must certify that you are Domestic Partners by completing and signing below.
I, {Name of Subscriber} and {Name of Partner} certify that we are Domestic Partners and that we:
We understand that a civil action may be brought against us for losses, including reasonable attorney fees and court costs, because of willful falsification of information in this Affidavit of Domestic Partnership.
We understand that willful falsification of information contained in this Affidavit may result in our termination of enrollment.
We certify under penalty of perjury under applicable state laws, that the foregoing is true and accurate to the best of our knowledge.
_____________________________________________________________________ Signature of Subscriber Date
_____________________________________________________________________ Signature of Domestic Partner Date
Md. Code Regs. 31.10.35.03
Regulations .03 adopted effective July 8, 2008 (35:12 Md. R. 1122)