Maryland Affidavit of Domestic Partnership Form

Use this template/form as an Affidavit of Domestic Partnership Form in the State of Maryland

maryland-affidavit-of-domestic-partnership

Text version of this Form

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AFFIDAVIT OF DOMESTIC PARTNERSHIP

The undersigned affiants, ____________________ and ____________________, swear or
affirm under the penalties of perjury and upon personal knowledge that the following statements are
true and correct:

1. That the undersigned affiants have established a domestic partnership with each other.

2. That each one of us is at least 18 years old.

3. That we are not related to each other by blood or marriage within four degrees of
consanguinity under the civil law rule.

4. That we are not married to or in a civil union or domestic partnership with any other person.

5. That we share a mutually interdependent personal relationship and we each contribute to the
maintenance and support of the other.

6. Attached to this affidavit is evidence of two of the following documents to support our claim
that we have established a domestic partnership:

_____ a. A joint housing lease or joint liability for a mortgage or other loan.

_____ b. Designation of one domestic partner as the primary beneficiary under a life
insurance policy or retirement plan of the other domestic partner.

_____ c. Designation of one domestic partner as the primary beneficiary under a Will
of the other domestic partner.

_____ d. A durable power of attorney for health care or finances granted by one
domestic partner to the other domestic partner.

_____ e. Joint ownership or lease of a motor vehicle.

_____ f. A joint checking account, joint investments, or a joint credit account.

_____ g. A joint renter=s or homeowner=s insurance policy.

_____ h. Coverage of one domestic partner under a health insurance policy of the other
domestic partner.

_____ i. Joint responsibility for the care of a child, such as guardianship or school
documents.

_____ j. A relationship or cohabitation contract.

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THIS AFFIDAVIT is being executed in order to establish that the undersigned affiants are
domestic partners for the purposes of (1) exercising health care facility visitation and medical
decision-making rights as provided in Senate Bill 566 (Chapter 590, Acts of Maryland 2008), (2)
claiming the exemption from inheritance tax for domestic partners as provided in Annotated Code
of Maryland, Tax-General Article, Section 7-203(l), and (3) asserting any and all other rights and
benefits afforded to domestic partners under Maryland law.

__________________________________________
____________________(Name)
________________________________(Address)
____________________(Phone number)

__________________________________________
____________________(Name)
________________________________(Address)
____________________(Phone number)

State of Maryland, County of ____________________: to wit

I hereby certify that on this ____ day of _________________________, 200__, before me, a
Notary Public for the State and County stated above, personally appeared ___________________,
known to me (or satisfactorily proven) to be the person who signed the foregoing Affidavit of
Domestic Partnership and made oath in due form of law under penalties of perjury that the matters
and facts set forth above are upon his/her personal knowledge and are true and correct.

Witness my hand and notarial seal.

__________________________________________
Notary Public
My commission expires:_____________

State of Maryland, County of ____________________: to wit

I hereby certify that on this ____ day of _________________________, 200__, before me, a
Notary Public for the State and County stated above, personally appeared ___________________,
known to me (or satisfactorily proven) to be the person who signed the foregoing Affidavit of
Domestic Partnership and made oath in due form of law under penalties of perjury that the matters
and facts set forth above are upon his/her personal knowledge and are true and correct.

Witness my hand and notarial seal.

__________________________________________
Notary Public
My commission expires:_____________

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