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12-9A.7 Severability.
The provisions of this Section are severable. If any of its provisions are held invalid by a court of competent jurisdiction, all other provisions shall continue in full force and effect.
(CBC 1985 12-9A.7; Ord. 1993 c. 12 § 7)
12-9A.8 Forms.
The City Clerk shall distribute copies of the forms following this Section to those who request them. Said forms shall be considered a part of this Section, and consist of the following:
(A) Statement of Domestic Partnership;
(B) Statement of Terminating Domestic Partnership; and
(C) Statement of Additional Dependents.
(CBC 1985 12-9A.8; Ord. 1993 c. 12 § 8)
Editor’s note:
The copies of the forms referred to herein may be found at the end of this Section.
12-9A.9 Employee Health Insurance Study.
(A) The city shall conduct a study of:
(1) Possible cost-saving measures which would reduce the city’s costs for the provision of health insurance benefits to its employees; and
(2) Costs and other issues related to the extension of health insurance benefits to city employees’ domestic partners and their dependents.
(B) This study shall be completed, and copies shall be made available to the Boston City Council, by June 30, 1994.
(Ord. 1993 c. 12 § 9)
FORM A: STATEMENT OF DOMESTIC PARTNERSHIP
CITY OF BOSTON OFFICE OF THE CITY CLERK Statement of Domestic Partnership We, Full name Date of Birth: / / Month/Day/Year and Full name Date of Birth: / / Month/Day/Year declare that: (1) we share basic living expenses; (2) we assume responsibility for each other’s welfare and for the welfare of any dependents listed below; (3) we are at least eighteen years of age; (4) we are competent to enter into a contract; (5) we are each other’s sole domestic partner; (6) we are not married to anyone, nor related to each other by blood closer than would bar marriage in the Commonwealth of Massachusetts; and (7) we shall notify the City Clerk of any change in the status of our domestic partnership. We became each other’s domestic partner on Our domestic partnership is a family which includes the following dependents I declare under the pains and penalties of perjury that to the best of my knowledge the foregoing statements are true and correct. Signed: Printed Name: Date: Signed: Printed Name: Date: |
FORM B: STATEMENT OF TERMINATING
DOMESTIC PARTNERSHIP.
CITY OF BOSTON OFFICE OF THE CITY CLERK Statement of Terminating Domestic Partnership I declare that: __________________________ (1) and I are Full name of domestic partner No longer domestic partners; and (2) I notified my former domestic partner of this statement in person/by certified mail (please circle one) on Date I declare under the pains and penalties of perjury that to the best of my knowledge the foregoing statements are true and accurate. Signed: Printed Full Name: Date: |
FORM C: STATEMENT OF ADDITIONAL
DEPENDENTS.
CITY OF BOSTON OFFICE OF THE CITY CLERK Statement of Additional Dependents Our domestic partnership/extended family (circle appropriate term) now includes the following additional dependents: I declare under the pains and penalties of perjury that to the best of my knowledge the foregoing statements are true and correct. Signed: Printed Full Name: Date: |
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