TERMINATION OF DOMESTIC PARTNERSHIP
UNIvERSITy OF CAlIFORNIA
UBEN 253 (10/06) University of California Human Resources and Benefits
Send completed form to:
UC HR/Benefits Records Management
P.O. Box 24570
Oakland, CA 94623-1570
Please photocopy this
form for your records.
SEE REvERSE FOR PRIvACy NOTIFICATIONS
EMPlOyEES/RETIREES: Use this form to notify UC that your domestic partnership has ended if you used form
UBEN 250 to establish your partnership. Do not use this form if your domestic partnership is registered with the
State of California or if your same-sex partnership was validly formed and registered in another jurisdiction and
the partnership is substantially equivalent to a California-registered domestic partnership. In that case, the
termination process is governed by the laws of the applicable jurisdiction.
If you registered your partnership with the State of California or another jurisdiction as described above and submitted a
copy of the appropriate registration form for UC benefit purposes and the partnership is terminating, you must submit a
filed copy of the State Notice of Termination of Domestic Partnership (SEC/STATE NP/SF DP-2) or a copy of a final judg-
ment of dissolution or nullity of the domestic partnership for a California registration or, if your same-sex partnership was
validly formed and registered in another jurisdiction and is substantially equivalent to a domestic partnership, a copy of
the form or order required by the other jurisdiction to document the termination or nullification of the partnership. In this
situation, UC’s form (UBEN 253) will not be accepted as proof that your partnership has terminated.
It is your responsibility to provide your former domestic partner with a copy of this termination form and the date benefits
end. Eligibility for survivor and/or death benefits stops on the date the domestic partnership ends.
Before you retire, you may submit a new declaration of domestic partnership any time you enter into another partnership.
Keep in mind, howev