Fillable Domestic Partnership Registration Affidavit (Page 2 of 3) in pdf

Prepared b y a nd r eturn t o:

Name

Mailing A ddress

City S T Z ip

ORANGE C OUNTY D OMESTIC P ARTNERSHIP R EGISTRATION A FFIDAVIT

Per O range C ounty C ode C hapter 2 2 A rticle V a nd C ity o f O rlando C ode C hapter 5 7 A rticle V I

We, t he u ndersigned c o-‐applicants, d o d eclare t hat w e m eet t he r equirements o f O range C ounty C ode C hapter 2 2

Article V a nd a gree t o t he f ollowing s tatements:

Initials o f

Co-‐

Applicant

I a m a t l east e ighteen ( 18) y ears o ld a nd c ompetent t o c ontract.

I a m n ot c urrently m arried u nder F lorida l aw, n or a m I a p artner i n a d omestic p artnership

relationship o r a m ember o f c ivil u nion w ith a nyone o ther t han t he c o-‐applicant.

I a m n ot r elated t o m y c o-‐applicant b y b lood a s d efined i n F lorida l aw.

I c onsider m yself t o b e a m ember o f t he i mmediate f amily o f t he c o-‐applicant, a nd I a m

jointly r esponsible f or m aintaining a nd s upporting t he r egistered d omestic p artnership.

I r eside i n a m utual r esidence w ith t he c o-‐applicant.

I w ill n otify t he C ounty C omptroller, i n w riting, i f t he t erms o f t he D omestic P artnership

Registration a re n o l onger a pplicable o r i f o ne o f t he d omestic p artners w ishes t o t erminate

the d omestic p artnership.

I a cknowledge t hat r egistration u nder t his o rdinance w ill g rant t o t he c o-‐applicant

healthcare f acility v isitation r ights, h ealthcare d ecisions, f uneral/burial d ecisions,

correctional f acility v isitation r ights, e mergency n otification o f f amily m embers, p re-‐need

guardian d esignation r ights, a nd e ducational p articipation r ights, a s r eflected i n t he C ity o f

Orlando D PR O rdinance u nder S ection 5 7.84.

In t he e vent t hat I h ave b een d etermined t o b e i ncapacitated t o p rovide i nformed c onsent

for m edical t reatment a nd s urgical a nd d iagnostic p rocedures, I d esignate t he c o-‐applicant

as m y s urrogate f or h ealth c are d ecisions. I f ully u nderstand t hat t his d esignation w ill p ermit

the c o-‐applicant t o m ake h ealth c are d ecisions a nd t o p rovide, w ithhold, o r w ithdraw

consent o n m y b ehalf; t o a pply f or p ublic b enefits t o d efray t he c ost o f h ealth c are; a nd t o

authorize m y a dmission t o o r t ransfer f rom a h ealth c are f acility. I f urther a ffirm t hat t his

designation i s n ot b eing m ade a s a c ondition o f t reatment o r a dmission t o a h ealth c are

facility.

I d esignate t he c o-‐applicant a s m y a gent t o d irect t he d isposition o f m y b ody f or f uneral a nd

burial.

List t he n ame(s) o f a ny d ependent(s) t hat r eside(s) w ithin t he m utual h ousehold o f c o-‐applicants w ho i s ( are):

1) a b iological, a dopted, o r f oster c hild o f a R egistered D omestic P artner; o r 2 ) a d ependent a s d efined u nder I RS

regulations; o r 3 ) a w ard o f a R egistered D omestic P artner a s d etermined i n a g uardianship o r o ther l egal

proceeding.

List D ependents:____________________________________________________________________________________________________

(If t he a bove l ine i s l eft b lank, i t w ill b e a utomatically a ssumed t hat t here a re N O d ependents.)

Form l ast r evised 7 /5/12

Domestic Partnership Registration Affidavit Page 2