AFFIDAVIT OF DOMESTIC PARTNERSHIP
EMPLOYEE INFORMATION
Employee Name (Last, First, Middle) / Employee ID # (5 digits)Address / City / State / ZIP
DOMESTIC PARTNER INFORMATION
Name (Last, First, Middle):Address / City / State / ZIP
To Apply During Open Enrollment Period:
You must have jointly shared the same permanent residence for at least 12 months immediately preceding the date of this Affidavit and intend to continue to do so indefinitely.
Please indicate the date you began living together:
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To Apply Outside Open Enrollment Period (Qualifying Event):
You must have jointly shared the same permanent residence for 12 months immediately preceding the date of this Affidavit and intend to continue to do so indefinitely.
Please indicate the date you began living together:
CERTIFICATION
We certify that the foregoing information is true and correct and understand that a false declaration of a domestic partnership or failure to file a timely notice of Termination of a Domestic Partnership form with the Kinder Morgan Benefit Department may result in a disciplinary action up to and including termination of employment at Kinder Morgan. We agree that in the event of a false declaration, or the failure to file a Termination of a Domestic Partnership form with the Kinder Morgan Benefit Department, Kinder Morgan may recover damages from either or both of us for all costs and expenses incurred by the Company as a result of that false declaration, including, without being limited to, attorneys’ fees incurred by Kinder Morgan to recover such damages.
DECLARATION
We, the undersigned, declare that:
1) We are at least 18 years of age and mentally competent to enter into a contract.
2) We are not married and are not the domestic partner or legal spouse of any other person, including a common law marriage.
3) We are not related by blood in a manner that would bar our marriage in the state of (state in which we reside) if we could or desired to lawfully marry.
4) At least twelve (12) months have passed since the termination of any previous domestic partnership or marriage.
5) We attest that our relationship is an exclusive mutual commitment that is similar to that of a married couple; that is,
· We are jointly responsible for each other for the necessities of life including each other’s debts; and
· We intend to remain in the relationship indefinitely; and
· We have agreed that in the event of dissolution of our domestic-partner relationship, we will make an equitable division of any earnings acquired during our domestic partnership and of property acquired with those earnings; that is, a division of property similar to that legally required of a married couple in the event of dissolution of marriage.
7) We are submitting the following supporting documentation to verify our cohabitation and interdependent financial relationship and understand that this Affidavit will not be processed without THREE individual pieces of supporting documentation:
· Cohabitation can be established by documents showing joint ownership of a home, condominium, mobile home or a lease for a residence identifying both partners as tenants or a utility bill for the residence with both partners’ names on the account
AND
· TWO documents establishing joint responsibility for finances, such as:
· Joint ownership of a motor vehicle
· Joint credit account (or co-applicant for the other’s credit card)
· Joint bank account
· Joint ownership of a major asset
· Joint liability for a debt
· Beneficiary designation (primary or secondary) under the other’s life insurance policy, retirement benefits account or IRA
· Documents demonstrating that one is executor of the other’s will
· Power of attorney for health care or financial management
· Adoption papers or legal guardianship demonstrating shared responsibility of minor children
· One is claimed as a dependent on the other’s federal tax return
8) I, an employee of Kinder Morgan, understand that another Affidavit of Domestic Partnership cannot be filed for at least twelve (12) months from the date that an Affidavit of Termination of Domestic Partnership is filed with the Kinder Morgan Benefit Department.
9) We provide the information as stated within this Affidavit to be used by Kinder Morgan for the sole purpose of determining our eligibility for domestic partnership benefits. We understand that the Company will take reasonable steps to limit access to this information. We further understand that Kinder Morgan, at its discretion, may request updated documentation at a later date to re-qualify our domestic partnership.
10) We understand that, by signing this Affidavit and as a result of Kinder Morgan providing benefits to us, that there may be legal and tax implications; therefore, we have been advised to consult with a legal/tax advisor regarding these implications.
11) We understand the extension of benefits for employees and their dependents under Kinder Morgan’s welfare plans may be revoked or modified by Kinder Morgan, at its sole discretion, at any time.
12) We understand that any person, employer or company who suffers any loss because of false statements contained in this Affidavit of Domestic Partnership may bring a civil action against us to recover their losses, including reasonable attorney fees. We understand that a false declaration of domestic partnership, material omission or information on this Affidavit, or failure to inform the Kinder Morgan Benefit Department of the termination of a domestic partnership in a timely manner is considered fraud and may result in disciplinary action of an employee up to and including termination of benefits and/or employment.
13) We affirm that the information we have provided is true and correct to the best of our knowledge. We know that knowingly providing an insurance company or other person an application for insurance or statement of claim containing any materially false information or concealing for the purpose of misleading, information concerning any fact material thereto, may subject us to legal liability or penalties.
Please complete this form, have it notarized and return it along with the required documentation to the following address:
Kinder Morgan
Benefit Department
1001 Louisiana Street, Suite 1000
Houston, TX 77002
Please keep a copy of this completed form for your records.
SIGNED DECLARATION AND NOTARIZATION (both signatures MUST BE notarized)
City of ______County of ______
Sworn to before me at ______, this
______day of ______, 20____.
Notary Public ______
My Commission expires: ______, 20____.
Employee Signature
Employee / Domestic Partners’ Street Address
Employee / Domestic Partners’ City, State & ZIP Code
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City of ______County of ______
Sworn to before me at ______, this
______day of ______, 20____.
Notary Public ______
My Commission expires: ______, 20____.
Domestic Partner Signature
Domestic Partner Social Security Number
Domestic Partner Date of Birth
Affidavit of Domestic Partnership Page 1 of 2 HR023
Rev: 07/16