COLLECTIVE BARGAINING AGREEMENT Between NEW YORK UNIVERSITY And LOCAL ONE SECURITY OFFICERS UNION
July 1, 2001 - June 20, 2006

APPENDIX C

NEW YORK UNIVERSITY - STATEMENT OF DOMESTIC PARTNERSHIP

I. DECLARATION

We, ___________________ and ________________________ certify that
employee (print) domestic partner (print)

we are domestic partners in accordance with the following criteria and eligible for benefits coverage as domestic partners under New York University's benefits program:

II. STATUS

1. We are each other's sole domestic partner and intend to remain so indefinitely.

2. We are of the same sex and neither one of us is married.

3. We are at least eighteen (18) years old and mentally competent to consent to a contract.

4. We are not related by blood to a degree of closeness which would prohibit legal marriage in the state in which we legally reside.

5. We reside together in the same residence and intend to do so indefinitely.

6. We are jointly responsible for each other's common welfare and share financial obligations. Joint responsibility for each other's common welfare and shared financial obligations must be demonstrated by the existence of three of the following. We have circled below the types of documentation that we will provide.

a. Joint mortgage or lease
b. Designation of domestic partner as beneficiary for life insurance
c. Designation of domestic partner as beneficiary for retirement contract
d. Designation of domestic partner as primary beneficiary in employee's will
e. Joint ownership of motor vehicle
f. Joint checking account or NYU Credit Union account
g. Joint credit account
h. Domestic partner registration with a state or municipal government
i. Health care proxy

7. We understand that as domestic partners we are subject to the same window period governing all other employees who are covered by or applying for benefit plan coverage. For employees, any births, adoptions, and domestic partnerships are all subject to a thirty-one (31) day limit on the enrollment period beginning on the date of the event (i.e., birth, adoption or signing of the statement of domestic partnership).

III. CHANGE IN DOMESTIC PARTNERSHIP

8. We agree to notify New York University's Benefits Office if there is any change in our status as domestic partners as certified in this statement which would make the domestic partner no longer eligible for University benefits (for example, a change in joint-residence or if we are no longer each other's sole domestic partner.) We will notify the University within thirty (30) days of such change by filing a Statement of Termination of Domestic Partnership ("Statement of Termination"). The Statement of Termination shall affirm that the domestic partnership status is terminated as of its date of execution and that a copy of the Statement of Termination has been mailed to the other party by the party authorizing such action.

9. After such termination, I ________________, understand that a subsequent Statement of Domestic Partnership cannot be filed until twelve months after a Statement of Termination has been filed with the University Benefits Office.

IV. ACKNOWLEDGMENTS

10. We understand that any person/employer/company who suffers any loss due to any false statement contained in this Affidavit may bring a civil action against either or both of us to recover their losses, including reasonable attorneys' fees.

11. We understand that any false or misleading statements made in order to receive benefits for which we do not qualify may subject the employee to disciplinary action.

12. We have provided the information in this statement for use by the University's Benefits Office for the sole purpose of determining our eligibility for domestic partnership benefits.

13. We declare under penalty of perjury that the statements above are tue and correct to the best of our knowledge.

Employee's signature
Date

Employee's Social Security number School/Division

Employee's/domestic partner's home address

Domestic partner's signature

Date

Domestic partner's Social Security number

Approved: For New York University

Name:
Title:
Date: