I, __________________________________________, declare that:
Employee (print)
1. __________________________________ and I are no longer Domestic Partners.
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
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