1. we are each other's sole domestic partner and are mutually responsible for each other's welfare;
2. we share a residence and have done so for at least six months;
3. we have a close and committed personal relationship and intend to remain so indefinitely;
4. we share basic living expenses (the cost of basic food, shelter, and any other expenses related to a joint domicile);
5. neither of us is married to anyone;
6. we are not related by blood in a way that would bar marriage in the state of Illinois;
7. we are both age 18 or older and mentally competent to consent.

We understand that IIT may ask us to provide evidence that the eligibility requirements are being met, according to IIT's policies for employee benefits.

We understand that this Certification shall be terminated upon a change in the circumstances attested to in this Certification. Employee agrees to provide a Certification of Termination of Domestic Partnership to IIT's Human Resources Department within 30 days of any change of the circumstances attested to in this Certification. Employee understands that if the domestic partner relationship terminates that a subsequent Certification can be filed after six months after a Statement of Termination of the previous partnership has been submitted to the university.

Employee understands that unless the domestic partner is a qualified dependent according to IRS regulations, IIT's cost of providing these benefits to the domestic partner is considered taxable income to Employee.

We understand that this information will be maintained as part of the employee's records and shall be disclosed as necessary for payroll purposes, tax reporting, human resource record-keeping, or as otherwise required by law.

We certify that the information contained in this Certification is true and correct. We understand that submitting false information may lead to legal action for recovery of expenses or other damages. Employee further understands that submitting false information on this Certification may result in disciplinary action or other actions by IIT, up to and including termination of employment.

_____________________________	_______________________
Employee Signature	Date

Please PRINT:
Employee Name
Partner's Name
Street Address
City/State/Zip