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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
Wisconsin Affidavit of Domestic Partnership
ET-2371 (11/2011) *ET-2371*
WISCONSIN DEPARTMENT OF EMPLOYEE TRUST FUNDS
P.O. BOX 7931
Madison, Wisconsin 53707-7931
1-877-533-5020 (toll free)
For Office
Use Only:
Affidavit Effective Date:
Reviewed By:
Affidavit of Domestic Partnership
Wis. Stat. § 40.02 (21d)
Beneficiary of
(if applicable):
Original Participant’s Name
Member Information (please print)
Original Participant’s SSN
Domestic Partner Information (please print)
Address of Residence Shared by Both Domestic Partners (please print)
Street Address
City
State
Country
This Affidavit certifies a domestic partnership ONLY for the purposes of retirement, insurance, and other benefits
administered by the Department of Employee Trust Funds (ETF). This document does NOT create a domestic
partnership as defined in Chapter 770 of the Wisconsin Statutes.
Affidavit Effective Date
For Chapter 40 benefit purposes this domestic partnership becomes effective on the date ETF receives this completed affidavit
or on January 1, 2010, whichever is later.
Declaration of Domestic Partnership
We, the undersigned, declare that we are in a domestic partnership as defined in Wisconsin Statute 40.02 (21d). We
understand that this affidavit is solely for the purpose of the benefit programs authorized in Chapter 40 of the Wisconsin
Statutes. We hereby certify that our partnership complies with all of the following criteria:
On the date this document was signed, both of us are legally competent and at least 18 years of age;
Neither of us is married to or in a domestic partnership with another person;
We are not related by blood in any way that would prohibit marriage under Wisconsin’s laws;
We consider ourselves to be members of each other’s immediate family;
We agree to be responsible for each other’s basic living expenses; and
We share a common residence.
You are considered to share a common residence even if any of the following conditions apply:
a. Only one partner has legal ownership of the residence (if ownership is applicable).
b. One or both partners have additional residences not shared with the other partner.
c. One partner leaves the common residence with the intent to return.
If this domestic partnership terminates, we agree to notify ETF by filing an Affidavit of Termination of Domestic Partnership
(ET-2372). A termination of a domestic partnership becomes effective on the date ETF receives the termination affidavit, or, if
earlier, on a 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).
If either partner has previously filed an affidavit certifying a different domestic partner, this affidavit will supersede any previously
filed affidavit and has the effect of terminating the previous domestic partnership.
We have read and understand this Affidavit of Domestic Partnership, including
the information on the back of this form. We understand that Wis. Stat. §
943.395 provides criminal penalties for knowingly making false or fraudulent
claims, and hereby certify that, to the best of our knowledge and belief, the
information we have provided is true and correct.
Notary Signature and Seal
State of___________ County of__________________
Signed before me by both partners on
_______________________
Date (mm/dd/yyyy)
____________________________________________
Notary Signature
___________________________________________
My commission is permanent/expires on
Member Signature
Date (mm/dd/yyyy)
Phone #
Domestic Partner Signature
Date (mm/dd/yyyy)
Phone #
Last Name First Name MI
Date of Birth
Gender (M/F)
Social Security Number
Last Name First Name MI
Date of Birth
Gender (M/F)
Social Security Number
Wisconsin Affidavit of Domestic Partnership
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