Domestic Partnership Registration Affidavit Page 3
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1
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C ounty
D PR
A ffidavit,
p age
2
We
u nderstand
t hat
t his
a ffidavit
f orm
a nd
o ur
D omestic
P artnership
r egistration
i nformation
i s
a
p ublic
record
u nder
F lorida
l aw.
W E
A FFIRMATIVELY
H OLD
T HE
O RANGE
C OUNTY
C OMPTROLLER
H ARMLESS
FROM
A NY
R ECORDING,
M ISTAKES
O R
D ELAYS
I N
P OSTING
U P-‐TO-‐DATE
I NFORMATION
T O
T HE
O N-‐
LINE
D ATABASE.
We
s wear
o r
a ffirm
u nder
p enalty
o f
p erjury
t hat
t he
s tatements
a nd
i nformation
p rovided
o n
t his
application
a bove
a re
t rue
a nd
c orrect.
Signed
o n
Witnesses
( may
n ot
b e
b lood
r elatives
o f
applicants)
Signature
o f
C o-‐Applicant
# 1
Signature
o f
W itness
1
Printed
N ame
o f
C o-‐Applicant
# 1
Printed
N ame
o f
W itness
1
Signature
o f
W itness
2
Printed
N ame
o f
W itness
2
Signature
o f
C o-‐Applicant
# 2
Signature
o f
W itness
1
Printed
N ame
o f
C o-‐Applicant
# 2
Printed
N ame
o f
W itness
1
Signature
o f
W itness
2
Printed
N ame
o f
W itness
2
Notarization
o f
b oth
s ignatures:
( required)
State
o f
County
o f
Sworn
t o
a nd
s ubscribed
b efore
m e
t his
_ _
__
d ay
o f
_ _____
______,
2 0_
__
by
a nd
who
a re
p ersonally
k nown
_ _____
o r
p roduced
i dentification(s)
____________________
Signature
o f
N otary
Form
l ast
r evised
7 /5/12
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