APPENDIX C AFFIDAVIT OF DOMESTIC PARTNERSHIP

New Shoreham School District

The purpose of this Affidavit is to qualify a domestic partner for receipt of any medical coverage and benefits to which a teacher's spouse and/or family members are entitled.

1. We hereby certify that as domestic partners, we have an exclusive mutual commitment similar to marriage and that we meet the following criteria:

a. We have been each other's domestic partner and have shared a common residence and we have every intention of remaining indefinitely in the relationship.

a. Neither of us is married to anyone else.

d. We are jointly responsible for each other's common welfare and basic living expenses.

e. We are both at least 18 years old and are mentally competent to consent to contract.

f. We are by law adults and not related by blood closer than would bar marriage in our state of legal residence.

g. Our domestic relationship is not illegal.

2. We agree to notify the New Shoreham School Department if the status of this relationship changes - including termination of the relationship or fail ure to meet any of the above criteria - by filing a Change of Status form no later than 30 days from the date of such change. It is understood that if this domestic partnership is terminated, a subsequent Declaration of Domestic Partnership cannot be filed until the later of 12 months after filing a Change of Status form or 12 months after coverage has been cancelled.