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Same-Sex Domestic Partner Health Stipend Reimbursement & Certification Form

If you have any questions, please contact Payroll & Records Management at (302) 831-8677 or email

Employee Information

Employee Name:
Employee ID:
Employee Department:
Campus Phone:

The effective date of the stipend (subsidy) will be the month following submission and approval of all
documents including the Affidavit of Domestic Partnership and proof of insurance. Completion of the
Domestic Partner Health Insurance Stipend form and documentation showing health insurance coverage
must be submitted to the Payroll Office. Follow up documents must be submitted on 3/31, 6/30, 9/30 and
12/31 via the Domestic Partner Health Stipend Reimbursement & Certification form. The University may
terminate the health insurance stipend if proof of continued health insurance coverage is not provided.

Insurance Information:

Name of Covered Individual:
Health Insurance Provider:
Period of Coverage Start Date: (mm/dd/yyyy)
Period of Coverage End Date: (mm/dd/yyyy)
Select Coverage Level:
Monthly Premium Amount*: $

*All reimbursements will be made to the employee rather than to any health plan provided.

I certify that I have incurred the expense(s) for which reimbursement is claimed and that:

My partner's employer does not provide health insurance coverage
My partner is not eligible for health insurance coverage
My same-sex domestic partner is not presently employed

I understand that the amount of the stipend will not exceed the maximum allowable amount nor will it
exceed the actual cost of my domestic partner's verified premium.

Name:   Date: (mm/dd/yyyy)

Attachments (Optional)
If you want to attach files, please use this section.

Office Use Only

Employee ID:


Earnings Code:


Effective Date:


End Date:


Earnings Amount:


Goal Amount:


Combo Code: