Benefits

Domestic Partners

General Information
Certification of Domestic Partnership Form

 

Statement of Termination of Domestic Partnership



LAFAYETTE COLLEGE

STATEMENT OF TERMINATION OF DOMESTIC PARTNERSHIP

 

 

I, __________________________________________, declare that:

Employee (print)

 

  1. __________________________________ and I are no longer Domestic Partners.

    2. Name of Domestic Partner (print)

  2. I make and file this Statement of Termination of Domestic Partnership in order to cancel the Statement of Domestic Partnership filed by me with Lafayette College

    3. on _______________________________.

  3. I mailed my former domestic partner a copy of this notice at this address ________________________________ on this date: _______________________.
  4. The termination of our domestic partnership was effective on this date:__________.

 

Signed: ___________________________________

Print Name: ___________________________________

Address: ___________________________________

Date: ___________________________________

 

 

State. Of Termination
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