ILLINOIS INSTITUTE OF TECHNOLOGY
CERTIFICATION OF THE TERMINATION OF SAME-SEX DOMESTIC PARTNERSHIP

 

I, (employee), declare that:
  1. and I are no longer domestic partners.

  2. I make and file this Certification of Termination of Domestic Partnership in order to cancel the Certification of Domestic Partnership filed by me with the university on: .

  3. I mailed my former domestic partner a copy of this notice to the following address:
    on: .

I understand that a new Certification of Same-Sex Domestic Partnership can be submitted only after six months after this Certification of Termination has been received by the university.

_____________________________ _______________________
Employee Signature Date

 
Please PRINT:
Employee Name
Street Address
City/State/Zip