Appendices

Feb 27, 2006 2:10 PM

Appendix 2

Art Institute of New York CityAffidavit of Domestic Partnership

Please complete and sign below in order to confirm your domestic partner’s eligibility for
benefits.

I,______________________ hereby certify that I and ________________have been domestic partners for at least 6 months, and :

1.      we are not legally married to any other individual;
2.      we are each eighteen (18) years of age or older;
3.      we are mentally competent to consent to contract when the domestic partnership began; and
4.      we agree to give notification of any change in the status of our agreement.

I understand that this affidavit shall be terminated upon the death of my domestic partner or by a change of circumstances attested to in this affidavit.  I agree to notify my Human Resources Department if there is any change of circumstances attested to in this affidavit within (30) days of a change.

I understand that domestic partners are eligible for enrollment only during open enrollment periods and that the non-employee domestic partner does not have rights to continuing coverage under federal law through COBRA.

I understand that the company will be deducting any premiums paid for my domestic partner on an after-tax vs. a pre-tax basis and the employer’s contribution will be considered as imputed income for the employee.

________________________________                    __________
Employee Signature                                                      Date
________________________________                    __________
Domestic Partner Signature                                           Date
________________________________                    __________
Director of Human Resources                                       Date