Domestic Partnership

You may cover your same or opposite sex domestic partner as your dependent for the purpose of health insurance coverage. A domestic partnership, for eligibility under the plan, is one in which you and your partner are 18 years of age or older, unmarried and not related in a way that would bar marriage. You must be living together, involved in a lifetime relationship and financially interdependent. At the time of application, you must have been in the partnership for six months.

Proof of Joint Responsibility for Basic Financial Obligations

Two Forms of Proof

You must submit two forms of proof from the list below to prove joint responsibility for basic financial obligations.

One of these proofs must be at least six months old on the date you submit this form. The second proof from this list must be dated within six months of the date you submit this form and must be a different form of proof than the older proof submitted.

Example: If you provide a statement from your joint bank account as your first form of proof, you may not provide a more recent statement from the same bank account as second form of proof.

Acceptable Proofs

□ Joint mortgage or lease agreement
□ Joint ownership of residence
□ Joint wills or designation of the Domestic Partner as executor and/or primary beneficiary
□ Designation of the Domestic Partner as beneficiary for life insurance or retirement benefits
□ Designation of the Domestic Partner as durable power of attorney
□ Health Care Power of Attorney
□ Joint obligation on a loan (may submit a creditor’s affidavit for a personal loan)
□ Joint ownership of a brokerage investment account
□ Joint insurance policy (homeowners’ or renters’ policy)
□ Joint ownership or lease of a motor vehicle
□ Joint financial responsibility for child care (e.g., school tuition, guardianship)
□ Joint household budget for the purpose of receiving government benefits
□ Status as an authorized signatory on the partner’s bank account, credit card or charge card
□ Designation of one partner as the representative payee for the other’s government benefit
□ Joint bank, joint credit card or joint charge card account statements, or letters from the financial institution
confirming effective date

Not Acceptable

Proofs such as a motor vehicle insurance policy listing the Domestic Partner as a driver or a phone bill listing the Domestic Partner as a user are not acceptable.

Proof of Cohabitation

One Form of Proof

You must submit at least one form of proof from the list below to prove that you and your Domestic Partner reside together.

All documents submitted for proof of cohabitation must be at least six months old as of the date you submit this form. This proof may be one document on which both names appear, or two separate documents that specify each partner’s residential address. Your proofs must contain a residential address — a P.O. Box is not an acceptable proof.

Acceptable Proofs

□ Bank statement mailed to residential address
□ Pay check stub
□ Driver’s license or automobile registration showing residential address
□ Insurance benefits statement mailed to residential address
□ Joint membership statement mailed to residential address (e.g., church or other organization)
□ Joint mortgage or lease agreement
□ Joint ownership of residence
□ Tax return listing residential address
□ Telephone/Utility bill mailed to residential address
□ Registration as a domestic partnership in a New York State municipality that has established such a procedure

Not Acceptable

Your proofs must contain a residential address — a P.O. Box is not an acceptable proof.

You and your Domestic Partner must be able to answer “YES” to all of the following statements and provide the required documentation in order for your Domestic Partner to qualify for coverage under NYSHIP

We are each 18 years of age or older.
We are not related in a manner that would bar marriage in New York State.
I am not legally married to anyone else. If I am divorced, I am submitting a divorce decree for my prior marriage. Legal separation does not constitute a termination of marriage. If I am widowed, I am submitting a copy of my deceased spouse’s death certificate.
My Domestic Partner is not legally married to anyone else. If they are divorced, I am submitting a divorce decree for their prior marriage. Legal separation does not constitute a termination of marriage. If my Domestic Partner is widowed, I am submitting a copy of their deceased spouse’s death certificate.
Neither I, nor my partner, have had a Domestic Partner enrolled in NYSHIP within the last year.
We have shared the same residence for at least the last six months and have included proof of cohabitation as described in Section B of this form.
We have had an exclusive mutual commitment to share responsibility for each other’s welfare and financial obligations for at least the last six months and we expect that commitment to last indefinitely. We included proof of joint responsibility for basic financial obligations as described in Section B of this form.
I, the enrollee, understand that I am required to file a completed Form PS-425.4, Termination of Domestic Partnership, within 30 days of the date my domestic partnership ends or when I no longer can provide proof of one or more of the above requirements.

Coverage Under NYSHIP

You and your Domestic Partner must be able to answer “YES” to all of the following statements and provide the required documentation in order for your Domestic Partner to qualify for coverage under NYSHIP

We are each 18 years of age or older.
We are not related in a manner that would bar marriage in New York State.
I am not legally married to anyone else. If I am divorced, I am submitting a divorce decree for my prior marriage. Legal separation does not constitute a termination of marriage. If I am widowed, I am submitting a copy of my deceased spouse’s death certificate.
My Domestic Partner is not legally married to anyone else. If they are divorced, I am submitting a divorce decree for their prior marriage. Legal separation does not constitute a termination of marriage. If my Domestic Partner is widowed, I am submitting a copy of their deceased spouse’s death certificate.
Neither I, nor my partner, have had a Domestic Partner enrolled in NYSHIP within the last year.
We have shared the same residence for at least the last six months and have included proof of cohabitation as described in Section B of this form.
We have had an exclusive mutual commitment to share responsibility for each other’s welfare and financial obligations for at least the last six months and we expect that commitment to last indefinitely. We included proof of joint responsibility for basic financial obligations as described in Section B of this form.
I, the enrollee, understand that I am required to file a completed Form PS-425.4, Termination of Domestic Partnership, within 30 days of the date my domestic partnership ends or when I no longer can provide proof of one or more of the above requirements.

Domestic Partnership

Proof of Joint Responsibility for Basic Financial Obligations

Two Forms of Proof

Acceptable Proofs

Not Acceptable

Proof of Cohabitation

One Form of Proof

Acceptable Proofs

Not Acceptable

You and your Domestic Partner must be able to answer “YES” to all of the following statements and provide the required documentation in order for your Domestic Partner to qualify for coverage under NYSHIP

Coverage Under NYSHIP

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