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Joint Affidavit of Life Partnership Template

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105 views73 pages

Joint Affidavit of Life Partnership Template

Uploaded by

Nathaniel
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class="loading" style="top: calc(50% + 20px);"></div><div id="pc1"><div
style="height: 0px;"></div><div class="pageNumV2">1 / 2</div><div id="p1"
name="p1"><div style="direction:ltr;margin-top:5px"><span
style="direction:ltr;">REPUBLIC OF THE PHILIPPINES) <br></span></div><div
style="direction:ltr;margin-top:5px"><span style="direction:ltr;">CITY OF
__________ &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;) &nbsp;S.S.
<br></span></div><div style="direction:ltr;margin-top:5px"><span
style="direction:ltr;"> <br></span></div><div style="direction:ltr;margin-
top:5px"><b><span style="direction:ltr;">JOINT AFFIDAVIT OF LIFE PARTNERSHIP
<br></span></b></div><div style="direction:ltr;margin-top:5px"><span
style="direction:ltr;">We: <br></span></div><div style="overflow-y: auto;
direction: ltr;"><div style="display: inline-block;"><table border="1"
style="direction:ltr"><tbody><tr><th><div style="direction:ltr;margin-
top:5px"><b><span style="direction:ltr;">Name <br></span></b></div></th><th><div
style="direction:ltr;margin-top:5px"><b><span style="direction:ltr;">Citizenship
<br></span></b></div></th><th><div style="direction:ltr;margin-top:5px"><b><span
style="direction:ltr;">Address <br></span></b></div></th></tr><tr><th><div
style="direction:ltr;margin-top:5px"><span style="direction:ltr;">John Michael P.
Tabornal <br></span></div></th><td><div style="direction:ltr;margin-top:5px"><span
style="direction:ltr;">Filipino <br></span></div></td><td><div
style="direction:ltr;margin-top:5px"><span style="direction:ltr;">Blk15 Lot18
Hyacinth Street, <span style="direction:ltr;">St. Joseph Village 9, Phase 1, <span
style="direction:ltr;">Brgy. Langgam, San Pedro, <span
style="direction:ltr;">Laguna
<br></span></span></span></span></div></td></tr><tr><th><div
style="direction:ltr;margin-top:5px"><span style="direction:ltr;">Allysa Jane A.
MOULIC <br></span></div></th><td><div style="direction:ltr;margin-top:5px"><span
style="direction:ltr;">Filipino
<br></span></div></td><td></td></tr></tbody></table></div></div><div
style="direction:ltr;margin-top:5px"><span style="direction:ltr;">both single, of
legal age, and of sound mind, after being sworn in accordance with law, <span
style="direction:ltr;">hereby jointly depose and say that:
<br></span></span></div><ul style="margin-left:30px;"><li><div
style="direction:ltr;"><span style="direction:ltr;">1. John Michael P. Tabornal is
an employee of Accenture, Inc. (“Company”), with office <span
style="direction:ltr;">address at 7th Floor Robinsons, Cybergate Tower 1, Pioneer
Street, Mandaluyong City, <span style="direction:ltr;">Philippines, since March 13,
2023 to date; <br></span></span></span></div></li></ul><div
style="direction:ltr;margin-top:5px"><span style="direction:ltr;">
<br></span></div><ul style="margin-left:30px;"><li><div
style="direction:ltr;"><span style="direction:ltr;">2. We have been living together
as life partners, in the same residential address, <span
style="direction:ltr;">exclusively, continuously and publicly since March 2020,
without the benefit of <span style="direction:ltr;">marriage and without any legal
impediment to marry under Philippine Laws (<i><span style="direction:ltr;">Note for
</span></i><i><span style="direction:ltr;">same sex partners please
add</span></i><span style="direction:ltr;">: “other than the fact that we are of
the same sex <span style="direction:ltr;">assignment at birth.”). &nbsp;See
attached Annex “A” and “B” – Certificates from the <span
style="direction:ltr;">Barangay showing that both affiants have the same home
address; &nbsp;<br></span></span></span></span></span></span></div></li></ul><div
style="direction:ltr;margin-top:5px"><span style="direction:ltr;">
<br></span></div><ul style="margin-left:30px;"><li><div
style="direction:ltr;"><span style="direction:ltr;">3. We are executing this
Affidavit for purposes of enrolling Allysa Jane A. Moulic as a <span
style="direction:ltr;">beneficiary in the roster of company benefits applicable to
employees with a declared <span style="direction:ltr;">Life Partner, subject to the
policies
and procedures of Accenture, Inc., until such time <span style="direction:ltr;">as
the Company revises, replaces and/or discontinues such benefits or the beneficiary
<span style="direction:ltr;">eligibility requirements therefor;
<br></span></span></span></span></span></div></li></ul><div
style="direction:ltr;margin-top:5px"><span style="direction:ltr;">
<br></span></div><ul style="margin-left:30px;"><li><div
style="direction:ltr;"><span style="direction:ltr;">4. We hereby agree to indemnify
the Company, its officers and affiliates, and hold it free <span
style="direction:ltr;">and harmless from any and all claims that may be filed all
third persons (including the <span style="direction:ltr;">legitimate/illegitimate
heirs of the Life Partners) that may arise in relation to any Life <span
style="direction:ltr;">Partner Benefits that may be given to us by the Company;
<br></span></span></span></span></div></li></ul><div style="direction:ltr;margin-
top:5px"><span style="direction:ltr;"> <br></span></div><ul style="margin-
left:30px;"><li><div style="direction:ltr;"><span style="direction:ltr;">5. We
acknowledge that, in the event that our life partnership no longer meet the life
<span style="direction:ltr;">partnership criteria set forth by the company, we will
no longer be considered Life <span style="direction:ltr;">Partners and John Michael
P. Tabornal will immediately file an Affidavit of <span
style="direction:ltr;">Termination of Life Partnership with the Accenture Benefits
Admin. Accordingly, <span style="direction:ltr;">Allysa Jane A. Moulic will no
longer be eligible for coverage or as beneficiary to the <span
style="direction:ltr;">roster of company benefits applicable to a declared Life
Partner; <br></span></span></span></span></span></span></div></li></ul><div
style="direction:ltr;margin-top:5px"><span style="direction:ltr;">
<br></span></div></div><hr class="pageHrV2"></div><div id="pc2"><div
class="pageNumV2">2 / 2</div><div id="p2" name="p2"><ul style="margin-
left:30px;"><li><div style="direction:ltr;"><span style="direction:ltr;">6. We
understand that any false or misleading statement made in order to receive benefits
<span style="direction:ltr;">for which we do not qualify will subject us to
financial responsibility for any benefits <span style="direction:ltr;">paid on us,
jointly or individually. In additions, Allysa Jane A. Moulic may be subjected <span
style="direction:ltr;">disciplinary action up to and including termination of
employment and possible charges <span style="direction:ltr;">of fraud.
<br></span></span></span></span></span></div></li><li><div
style="direction:ltr;"><span style="direction:ltr;">7. We attest, under pains and
penalties of perjury, to the truth of the foregoing and for <span
style="direction:ltr;">any legal purpose it may serve.
<br></span></span></div></li></ul><div style="direction:ltr;margin-top:5px"><span
style="direction:ltr;"> <br></span></div><div style="direction:ltr;margin-
top:5px"><span style="direction:ltr;">IN WITNESS WHEREOF, we have hereunto set our
hands this ___ day of __________, <span style="direction:ltr;">_____, in the City
of _________, __________, Philippines. &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;
<br></span></span></div><div style="direction:ltr;margin-top:5px"><b><span
style="direction:ltr;"> <br></span></b></div><div style="direction:ltr;margin-
top:5px"><span style="direction:ltr;"> &nbsp;<br></span></div><div style="overflow-
y: auto; direction: ltr;"><div style="display: inline-block;"><table border="1"
style="direction:ltr"><tbody><tr><th><div style="direction:ltr;margin-
top:5px"><span style="direction:ltr;">_____________________________________<span
style="direction:ltr;">___ <br></span></span></div></th><th><div
style="direction:ltr;margin-top:5px"><span
style="direction:ltr;">_____________________________________<span
style="direction:ltr;">___ <br></span></span></div></th></tr><tr><th><div
style="direction:ltr;margin-top:5px"><b><span style="direction:ltr;">Affiant
<br></span></b></div></th><td><div style="direction:ltr;margin-top:5px"><b><span
style="direction:ltr;">Affiant
<br></span></b></div></td></tr></tbody></table></div></div><div
style="direction:ltr;margin-top:5px"><span style="direction:ltr;">
<br></span></div><div style="direction:ltr;margin-top:5px"><span
style="direction:ltr;"> <br></span></div><div style="direction:ltr;margin-
top:5px"><span style="direction:ltr;">Republic of the Philippines }
<br></span></div><div style="direction:ltr;margin-top:5px"><span
style="direction:ltr;">City of ________________ } <br></span></div><div
style="direction:ltr;margin-top:5px"><span style="direction:ltr;">
<br></span></div><div style="direction:ltr;margin-top:5px"><span
style="direction:ltr;">SUBSCRIBED and SWORN to before me, in the City of
__________, __________, <span style="direction:ltr;">Philippines, this ____ day of
________________ the affiants exhibiting to me the following:
<br></span></span></div><div style="overflow-y: auto; direction: ltr;"><div
style="display: inline-block;"><table border="1"
style="direction:ltr"><tbody><tr><th><div style="direction:ltr;margin-
top:5px"><b><span style="direction:ltr;">Name <br></span></b></div></th><th><div
style="direction:ltr;margin-top:5px"><b><span style="direction:ltr;">Government
ID/No. <br></span></b></div></th><th><div style="direction:ltr;margin-
top:5px"><b><span style="direction:ltr;">Issued on/at
<br></span></b></div></th></tr><tr><th><div style="direction:ltr;margin-
top:5px"><span style="direction:ltr;"> <br></span></div></th><td><div
style="direction:ltr;margin-top:5px"><span style="direction:ltr;">
<br></span></div></td><td><div style="direction:ltr;margin-top:5px"><span
style="direction:ltr;"> <br></span></div></td></tr><tr><th><div
style="direction:ltr;margin-top:5px"><span style="direction:ltr;">
<br></span></div></th><td><div style="direction:ltr;margin-top:5px"><span
style="direction:ltr;"> <br></span></div></td><td><div style="direction:ltr;margin-
top:5px"><span style="direction:ltr;">
<br></span></div></td></tr></tbody></table></div></div><div
style="direction:ltr;margin-top:5px"><span style="direction:ltr;"> &nbsp; &nbsp;
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;
&nbsp; &nbsp; &nbsp; &nbsp;Notary Public <span style="direction:ltr;"> &nbsp;
&nbsp; &nbsp; &nbsp;<br></span></span></div><div style="direction:ltr;margin-
top:5px"><span style="direction:ltr;">Doc. No. ____; <br></span></div><div
style="direction:ltr;margin-top:5px"><span style="direction:ltr;">Page No. ____;
<br></span></div><div style="direction:ltr;margin-top:5px"><span
style="direction:ltr;">Book No. ____Series of 20__. <br></span></div></div><hr
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