RCUH Policies and Procedures
of the University of Hawai‘i
Human Resources Department
Declaration of Termination of Domestic PartnershipEUTF DECLAON OF TERMINATION OF DOMESTIC PARTNERSHIP
I, ______________________________ (employee), an employee of the RCUH, declare that, as of_________________________________ (date), am no longer in a
domestic partnership with _______________________________ (domestic partner) because:
Our domestic partnership no longer meets all the status criteria set forth in our Declaration of Domestic Partnership, or
The domestic partner deceased as of __________________ (date), or
Our domestic partnership terminated or dissolved as of ________________ (date).
II. TERMINATION OF COVERAGE
I understand that termination of coverage of the domestic partner will be effective upon the RCUH’s receipt of this Declaration, and continuation of coverage under COBRA is not provided for the domestic partner.
I affirm, under penalty of perjury, that the statements in this Declaration are true and correct.
___________________________________ _______________ Employee Signature Date
RCUH Form B-15
Created 10/26/2013, Rev. 06/17/2014, 03/30/2016