Declaration Of Domestic Partnership Form - County Of Champaign, Illinois
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2DECLARATION OF DOMESTIC PARTNERSHIP
(County of Champaign, Illinois)
I,
__________________________ AND I, ___________________________
DO HEREBY DELCARE
that we have thoroughly read and fully understand this Declaration and the Domestic Partnership Registry
Ordinance (attached hereto and made a part thereof) upon which it is based, and that we are in full
compliance with all the requirements for a domestic partnership and that we hereby declare under oath to be
DOMESTIC PARTNERS as defined in An Ordinance Establishing A Domestic Partner Registry, and
enacted pursuant to a vote of the Champaign County Board as Resolution No. 5208.
WE FURTHER DECLARE, as domestic partners, that we have chosen to share one another’s lives in a
committed relationship of mutual caring and that we are jointly responsible and obligated for the necessities
of life incurred during our domestic partnership.
THE UNDERSIGNED AUTHORIZE the County of Champaign acting pursuant to Resolution No. 5208
to issue certified copies of said Declarations to members of the public upon request and payment of the
required fees as required under the Freedom of Information Act.
THE UNDERSIGNED AGREE to file an Affidavit of Termination of Registered Domestic Partnership
within 30 days of any change in the partnership which causes it not to satisfy any one of the requirements
for a domestic partnership as set forth in Resolution No. 5208 of the County of Champaign.
THE UNDERSIGNED UNDERSTAND that any person, including any employer, who relies upon a
registered Declaration of Domestic Partnership to the person’s or employer’s detriment as a result of a false
statement contained therein or a false assertion of family membership; or as a result of a failure to notify the
Insurance Specialist, Administrative Services Department, or any person or employer previously notified of
the Domestic Partnership of a change in the status of the Domestic Partnership or family membership, shall
have the right to bring a civil action in any court of competent jurisdiction against the appropriate Domestic
Partner(s) to recover damages for such detrimental reliance.
THE UNDERSIGNED FURTHER UNDERSTAND that the execution of this Declaration may be further
construed by a court of law as creating enforceable, legal obligations between the persons executing the
same.
Executed, this __________ day of ________________, 20_____.
(month)
_________________________________________ and ____________________________________________
Name of Domestic Partner
Name of Domestic Partner
_________________________________________
____________________________________________
Address
Address
_________________________________________
____________________________________________
Signature
Signature
Proof of Age verified _______
Proof of Age verified ________
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