Form PC-2109 Affidavit Declaring Domestic Partner Relationship

OMB Control No. 0420-xxxx
Expiration date xx/xx/20xx

AFFIDAVIT DECLARING DOMESTIC PARTNER RELATIONSHIP
DOMESTIC PARTNER means a person in a committed relationship with the applicant for Peace Corps
Volunteer service.
DOMESTIC PARTNERSHIP means a committed relationship between two adults that meets all of the
requirements below.
I, _________________________________, declare that __________________________________and I:
[full name of applicant]
[full name of domestic partner]
1. Are both applicants for Peace Corps Volunteer service;
2. Are each other’s domestic partner and intend to remain committed to one another indefinitely;
3. [Please check one]
□ have a common residence, and intend to continue the arrangement; or
□ would have a common residence, but are prevented from having one due to the following
circumstances (please explain):
______________________________________________________________________________
______________________________________________________________________________
4. Are at least 18 years of age and mentally competent to consent to contract;
5. Share responsibility for a significant measure of each other’s common welfare and financial
obligations;
6. Are not married to, joined in civil union with, or domestic partners with anyone else; and
7. Are not related in a way that would prohibit legal marriage in the state in which we reside.
I further declare that I 8. Agree to notify Peace Corps of any dissolution of the domestic partnership not later than 15 days after
the date of dissolution of the domestic partnership; and
9. Understand that falsification of information within this affidavit may constitute a criminal violation
under 18 U.S.C. 1001 and may lead to disciplinary action.
I declare under penalty of perjury that the foregoing is true and correct.
_____________________________________________
Applicant’s Signature

__________________________
Date:

This information is being collected pursuant to 22 U.S.C. 2504(a). It will be used in determining your eligibility for Peace Corps
Volunteer service. Response is voluntary, but without it, Peace Corps will be unable to determine eligibility for placement as a
couple. This information may be used under the Privacy Act consistent with uses of information in PC-17 (Volunteer Records).
See 65 Fed. Reg. 53,722 (Sept. 5, 2000) and 50 Fed. Reg. 1950 (Jan. 4, 1985).
Burden Statement: Public reporting burden for this collection of information is estimated to average 2 minutes. This estimate includes the time
for reviewing instructions and completing the collection of information. An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden, to: FOIA Officer, Peace Corps, 1111 20th
Street, NW, Washington, DC 20526 ATTN: PRA (0420-####).
(PC-2109 (12/2013))