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Office of Student Health Benefits 2012-2013 Declaration of Domestic Partnership To enroll a domestic partner as a dependent on a University-sponsored Office of Student Health Benefits administered health plan complete this form and submit to the Office of Student Health Benefits. Please keep a copy of this form for your records. A. Primary Member Information Name last first middle initial Please print Date of birth mm/dd/yyyy Gender U of M ID number Social Security number Street address city...
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