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Wisconsin Affidavit of Domestic Partnership

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This affidavit provided by Wisconsin Department of Employee Trust Funds (ETF) is completed by affiants to confirm a domestic partnership only for retirement, insurance and other benefits managed by the ETF.

Wisconsin Affidavit of Domestic Partnership Page 2
Wisconsin Affidavit of Domestic Partnership
ET-2371 (11/2011) *ET-2371*
General Information
Purpose
The purpose of this affidavit is to certify a domestic partnership solely for the purposes of the benefit programs authorized
under Chapter 40 of the Wisconsin Statutes, which are administered by the Department of Employee Trust Funds (ETF).
This includes but is not limited to the Wisconsin Retirement System, the State of Wisconsin Group Health Insurance
Program, and the Wisconsin Deferred Compensation Program. To be treated as a valid domestic partnership for Chapter
40 benefit purposes, both parties must meet all of the qualifying criteria listed on the affidavit form. Failure to timely
notify ETF of the creation or termination of a domestic partnership could result in the delay or loss of benefits.
Certifying a domestic partnership through this affidavit does not create a domestic partnership under Wisconsin Statute
Chapter 770, nor does it constitute a beneficiary designation form. Registration on the domestic partner registry
under Chapter 770 does not create a domestic partnership for Chapter 40 benefit purposes. The ONLY way to
establish a domestic partnership for Chapter 40 benefit purposes is by filing this completed affidavit with ETF.
For a detailed overview of Chapter 40 domestic partner benefits, please see the publication Domestic Partner Benefits
(ET-2166).
There are tax consequences to providing certain benefits for domestic partners; you may need to contact the IRS and/or
your tax preparer for further information regarding the tax liabilities related to domestic partner benefits.
How to File an Affidavit of Domestic Partnership
Provide all of requested information on the affidavit.
Only one affidavit need be submitted, even if your domestic partner is also an employee.
If you are entitled to a benefit as the beneficiary of a WRS participant, complete the “Beneficiary of” information.
Both parties must sign the affidavit before a notary.
ETF must receive your signed (by both partners) and notarized affidavit for the partnership to be considered effective.
Submit your completed affidavit directly to ETF at P.O. Box 7931, Madison, WI 53707-7931. ETF will notify
you of your Chapter 40 domestic partnership effective date when we acknowledge your affidavit.
You may send the affidavit to ETF by fax at 608-267-4549. However, the notary seal must be visible in the electronic
copy; otherwise your affidavit will be rejected.
ETF must collect data such as Social Security numbers, gender and age for benefit administration purposes.
Individual personal information is confidential under Wisconsin law, and is not considered a public record.
When a Chapter 40 Domestic Partnership Becomes Effective
For Chapter 40 benefit purposes the domestic partnership certified in this affidavit becomes effective on the date ETF
receives this completed affidavit, regardless of how long the actual domestic partner relationship has been in force.
However, for Chapter 40 benefit purposes a domestic partnership cannot become effective before January 1, 2010, the
effective date specified in the Chapter 40 domestic partner provisions in 2009 Wisconsin Act 28.
Affidavits Received after Date of Death – An Affidavit of Domestic Partnership (ET-2371) received by ETF after the
date of death of either the employee/retiree or the domestic partner is invalid, and shall have no force or effect.
Termination of Domestic Partnership – Once received by ETF, for Chapter 40 benefit purposes your domestic
partnership remains in force until the earliest of the following dates:
o The date that ETF receives a notarized Affidavit of Termination of Domestic Partnership form (ET-2372)
signed by the employee/retiree.
o The date that ETF receives a valid Affidavit of Domestic Partnership (ET-2371) certifying that either the
employee/retiree or the domestic partner is now a partner in a different domestic partnership; the new
affidavit supersedes any previously filed Affidavits of Domestic Partnership.
o The date established to the Department’s satisfaction that the domestic partnership certified in this affidavit no
longer meets the definition of a domestic partnership in Wisconsin Statute 40.02 (21d).
Any Affidavit of Domestic Partnership that is not signed by both partners and notarized will be rejected, and for Chapter 40
benefit purposes the domestic partnership will not be in force. The Chapter 40 domestic partnership will not become
effective until ETF receives a new, properly completed affidavit.
Health Insurance
If you are first enrolling your domestic partner in the State of Wisconsin Group Health Insurance Program,
you must provide a copy of this affidavit to your employer with your health insurance application.
If you had a previous spouse or domestic partner who was covered under your State of Wisconsin Group Health
Insurance plan, you may not enroll a new spouse or domestic partner in your health insurance plan until six months
after the date on which your marriage or domestic partnership terminated.
If you fail to timely notify ETF of the termination of this domestic partnership, and medical expenses have been
erroneously paid on your domestic partner’s behalf, you are responsible for repaying any overpaid benefits.
Wisconsin Affidavit of Domestic Partnership
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