1. We are each other's sole domestic partner, have been a member of this partnership for the last six (6) months, and intend to remain in this partnership indefinitely.
2. Neither one of us is married.
3. We are at least eighteen (18) years of age and mentally competent to consent to contract.
4. We are not related by blood or adoption to a degree of closeness.
5. We have residence for at least six (6) consecutive months and intend to do so indefinitely.
6. We are jointly responsible for each other's common welfare and financial obligations.
7. We meet or agree to meet the requirements of any applicable federal, state or local laws or ordinances for domestic partnership.

8. We agree to notify the Group within thirty (30) days if our domestic partnership no longer meets the criteria attested to in this affidavit which would make us no longer eligible for benefits (for example, a change in joint residence or if we are no longer each other's sole domestic partner.) It is understood that termination of coverage for a domestic partner does not qualify that person for COBRA continuation coverage.
9. In the event that my domestic partnership terminates, I understand that a subsequent Affidavit of Domestic Partnership cannot be filed for at least six (6) consecutive months from the date the benefits were cancelled. Please type your name below.

10. We understand that we must provide copies of at least three (3) documents showing proof of our financial interdependency for six (6) months to the Group which will be forwarded to ATOMIC Design for review and approval.
    
    Such documents could include the following:
    
    1. a copy of domestic partnership agreement;
    2. evidence of joint purchase of a home;
    3. a copy of a lease for a residence identifying both parties as responsible for payment of rent;
    4. evidence of a joint checking account;
    5. evidence of a joint savings account;
    6. a title for a car showing joint ownership;
    7. evidence of joint liability for credit cards;
    8. a copy of the form specifying that the domestic partner is the beneficiary of life insurance;
    9. evidence that the domestic partner is the beneficiary of the employee's retirement account;
    10. evidence of durable powers of attorney for property or health;
    11. wills specifying the domestic partner as the major recipient of employee's financial assets.

11. We have provided the information in this affidavit for use by the Group for the sole purpose of determining our eligibility for domestic partner benefits.

12. We understand that current Internal Revenue Service regulations do not exempt benefit premiums paid by an employer on behalf of an employee's domestic partner. For this reason, my employer will include the value of its health care contribution in my (the employee) taxable income.

13. We understand that any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

14. We affirm, under penalty of perjury and in the presence of the Group Administrator, that the assertions in this affidavit are true to the best of our knowledge.

PLEASE NOTE

Once you submit the form, it will be securely routed to ATOMIC's HR team for review. They will carefully review the documentation provided and determine whether the request can be approved. You will receive an email notification with their decision and any next steps. Thank you for taking the time to complete this process. If you have any questions, please reach out to ATOMIC's HR team for assistance.