F02330 Affidavit of Domestic Partnership

Instructions:    

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Information on Completing the Form

This form pertains to same-sex and opposite sex domestic partnerships only. Do not use this form for same-sex marriages.

a) Please fill out the form electronically, except for signature blocks.

b) Return this form with all other required documents as specified in the checklist to the HR Operations via (Please select one transmittal format, and submit only once):

1. Interoffice mail to MSN G2-202; or 2. Fax +1 (202) 522-7026.

Need Help? 

If you are experiencing any issues, please contact HR Operations via email: hroperations@worldbank.org  or phone 202-473-2222 or 5220+32222.

Revision 26 Jan 2024

Staff member's and Domestic Partner's information

Please select one:

World Bank Group UPI*

Staff Name*

Gender*

Domestic Partner UPI (if exists):

Domestic Partner Name:*

Gender*

Domestic Partner Date of birth:*

Domestic Partner Nationality:*

Domestic Partner SSN (if exists):

Domestic Partner US Visa Status:*

PR list A#:

Other, Specify:

Domestic Partner Employer:*

Please indicate the current address of you and your DP. You and your DP must have cohabitated for at least 12 months prior to this registration request.

Address1:*

Address2:

City:*

State:*

Zip/Postal Code:*

Country:*

Start Date of Cohabitation:*

If DP registration is approved and your partner is eligible for enrollment, do you wish to include him/her in the World Bank Group medical insurance plan you are participating in?*

If DP registration is approved and your partner becomes your first eligible dependent, do you wish to elect optional dependent life insurance (HQ staff only)

Domestic Partner's Children

Does your partner have a child(ren) from previous marriage / relationship? 

Last Name*

First Name*

Middle Name

Date of birth*

Does your partner's child also reside in your household?*

If Domestic Partnership is approved and the child is eligible for enrollment, do you wish to include him/her in the medical insurance you are participating in?*


Certification and Signature

The above-named individuals hereby certify that we are domestic partners in accordance with the following criteria. We:

    a) are not related by blood to a degree that would bar marriage where we reside;

    b) are not presently married or partnered to anyone else;

    c) are each other’s sole domestic partner and intend to remain so indefinitely;

   d) are legally competent to contract and of lawful age to marry;

   e) I have a certificate of registration of the domestic partnership from the national authorities (e.g., certificate of     registration of a civil partnership in the UK, a pacte civil de solidarite (PACS) in France, etc.) OR

      1) have resided together in the same residence for at least 12 months and intend to do so indefinitely and;

      2) have been jointly responsible to each other for basic living expenses and have joint financial                           commitment for at least 12 months and intend to do so indefinitely

      3) attest that the attached documentation in support of our domestic partnership is true and accurate.

Signature of Staff Member

Date

Signature of Domestic Partner

Date

and

appeared before me personally and on oath acknowledged or affirmed that they each have read and understood the foregoing, that the representations therein are true to the best knowledge and belief of each of them, and that each of them has freely executed the same for the purpose of registering themselves as domestic partners with the World Bank Group. In witness whereof, I have signed my name and affixed my seal as of the day and year next above written.

Notary Public:

Required Supporting Documentation

Important Notice: Please make sure that ALL applicable required documentation is included with this form to avoid delays in the review and processing of your request. Any documents that are not in English must be translated, and attached with the original version. If you have any questions regarding the requirements, please contact HR Operations at 202-473-2222 prior to submitting anything for review and processing.

Please check all documents you are submitting with this form:

Personal Information. Submit document(s):

Birth certificate, passport page or other government national/family registry of domestic partner showing legal name, nationality and birth date. 

Certificate of registration of the domestic partnership from the national authorities (e.g., certificate of registration of a civil partnership in the UK, a pacte civil de solidarité (PACS) in France, etc.).The text will appear here

If you DO NOT have a certificate of registration of the domestic partnership from the national authorities, you must submit documents from Cohabitation and Joint Financial Commitment sections below.

Cohabitation: Submit at least one document from the list below, showing you and your partner had the same address for atleast 12 continuous months prior to your domestic partnership application:

 Joint lease(s) or mortgage(s) with you and your partner;

 Driver’s licenses;

 Voter registration cards;

 Tax filing documents;

 Bills for services, (for example, phone, utility);

 Magazine subscriptions;

 Written, signed statement from your landlord, combined with mail to you and your partner to that address;

Other evidence from a government authority or an employer which shows proof of address and supports your 12 month   cohabitation.

Joint Financial Commitment: Submit one or more documents from the list showing joint financial commitment for at least 12 months prior to your domestic partnership application:

 Joint bank account, credit card, or mortgage statements;

 Joint title or other proof of shared ownership of assets, for example property or vehicles;

Testamentary documents naming the partner as beneficiary and/or executor of estate or proof of designating partner as beneficiary of a retirement savings plan or life insurance proceeds;

Confirmation of joint health insurance plan participation from other employer/vendor for you and your partner;

 Other financial documents that legally bind you or your partner to each other’s assets;

Other legal documents that legally bind you or your partner to each other, for example naming your partnerThe text will appear here

Attention: In cases where none of the documents referenced above are available, or in situations where cohabitation has not been possible, a staff member may present other evidence that, in his/her mind, establishes proof of the couple’s domestic partnership, for example: affidavits sworn to or affirmed by third parties having personal knowledge of the bona fides of the domestic partnership; letters; photographs; telephone records; email trails. These cases will be escalated to the HR Operations Manager or a designated official for review and decisions. In consultation with the Bank’s Legal Department, the HR Operations Manager or designated official may, at his/her discretion, decide to accept the evidence presented in lieu of the documents referenced above.

Domestic Partner’s Child(ren) Documentation

Copy of the child's Birth Certificate.

Proof your partner's child does reside in your household (e.g. school reports, etc.)

After filling this document, you must sign and date it before returning this document to the World Bank Group. Please ensure ALL information in the submission form is complete and accurate before printing the form. This will generate your form(s) as a PDF file. Review the file for accuracy and completeness. If there is an error, please start a new form.