GME Division of Medical Education
Graduate
Medical Education

AFFIDAVIT OF DOMESTIC PARTNERSHIP

I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE STATEMENTS BELOW ARE TRUE AND CORRECT.

  1. That the partnership between:
    and
    Commenced on:
  2. That the above named persons are not related to each other.
  3. That the above named persons have assumed mutual obligations for the welfare and support of each other.
  4. That the above named persons have been living together as a couple in the same household for at least six months
  5. That neither of the above named persons has had a different partner less that six months before the date of this affidavit.

 

 

Date:  

 

 

Name Signature

 
Name Signature

 

[PLEASE NOTE: NOTARIZATION IS OPTIONAL]


STATE OF
County of
On before me,
Personally appeared

Personally know to me -OR- proved to me on the basis of satsifactory evidence to the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capcity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.



WITNESS my hand and official seal:

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