Affidavit of Domestic Partnership

INSTRUCTIONS:

Employee Information / Last First Middle
Name: / EMPLOYEE #: ______
Your employee # can be found on the top right corner of your pay stub. SSN: - -
/ address:
City: / State: / Zip code:
Daytime telephone #: ( ) -
Domestic Partner Information / Name: / SSN: - -
DOMESTIC PARTNER’S (Month/day/year)
Date of birth: male female / phone #: ( ) -
Certification of Partnership / We certify that we are domestic partners and we:
1.  are in a mutually exclusive relationship, are each other’s sole domestic partner, have been so for at least six months and intend to remain so indefinitely;
2.  are both at least 18 years of age (or at least age of consent in the state in which we live);
3.  have not been married to anyone else within the last six months;
4.  are not related closely enough by blood to bar marriage in the state in which we reside;
5.  reside together in the same principal residence, have done so for at least the past six months and intend to do so indefinitely;
6.  have joint responsibility for each other’s welfare and financial obligations and can upon request show evidence of such responsibility in two of the following forms:
·  registration in a state or locality that allows for registration of domestic partners, or
·  joint mortgage, lease or deed, or
·  joint bank account or credit cards, or
·  designation of the domestic partner as beneficiary for life insurance, retirement benefits, will or trust, or
·  durable property or health care power of attorney.
We understand that we are obligated to file a Notice of Termination of domestic partnership with the Service Center within 31 days of the date on which we no longer meet the criteria for a domestic partnership. We further understand that acknowledging our domestic partner relationship in this statement may subject us to tax or other legal obligations and that we should consult our attorney and/or tax advisor.
Signatures / Employee Signature: / Date:
DOMESTIC PARTNER Signature: / Date:

Please forward this completed form and all required attachments (if applicable) to: FORM 3838 10/08/07

McDonald’s Service Center Dept. 238, McDonald’s Corporation, 2111 McDonald’s Drive, Oak Brook, IL, 60523
Telephone #: (877) 623-1955 Fax #: (630) 623-5027 E-mail address: