Notice of Termination of Domestic Partnership

Employee Information / LastFirstMiddle
NAME: / EMPLOYEE #: ______
Your employee # can be found on the top right corner of your pay stub.
ADDRESS:
CITY: / STATE: / ZIP CODE:
DAYTIME TELEPHONE #: ( ) -
Domestic Partner Information / NAME:
DOMESTIC PARTNER’S (MONTH/DAY/YEAR)
DATE OF BIRTH: MALE □ FEMALE □ / PHONE #: ( ) -
Qualifying Criteria / You can include your same-sex or opposite-sex domestic partner as an eligible dependent in the medical, vision supplement, dental, employee assistance and/or life insurance plans as long as you meet the qualifying criteria that you and your partner:
  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. are not related closely enough by blood to bar marriage in the state in which we reside;
  4. reside together in the same principal residence, have done so for at least the past six months and intend to do so indefinitely;
  5. 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

Termination Certification
I certify that one or more of the criteria for domestic partnership listed above ceased to be accurate as of the date indicated. / DATE: ______
or
The domestic partner listed above died on the date indicated. / DATE: ______
I understand that for purposes of McDonald’s welfare plan benefits (such as medical, dental, vision, employee assistance or life insurance), our domestic partnership is accordingly terminated as of the date indicated above. I further understand that any applicable domestic partner coverage I had in effect under the applicable McDonald’s welfare plans will terminate effective as of the last day of the month in which the domestic partnership terminated.
Signature / EMPLOYEE SIGNATURE: / DATE:

Please forward this completed form and all required attachments (if applicable) to:

McDonald’s Service Center Dept. 28, McDonald’s Corporation, 2111 McDonald’s Drive, Oak Brook, IL 60523

Telephone #: (877) 623-1955 Fax#: (630) 623-5027 E-mail address:

To confirm receipt of your documents please contact the Service Center. Representatives are available M – F 8:00am – 5:00pm CT, excluding holidays.

FORM 38391/1/2016