Registration Of Domestic Partnership Affidavit Form - County Of Champaign, Illinois
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1Identification Presented:
Type: ____________________
ID#_____________________
File Date______________
Type: ____________________
ID# _____________________
REGISTRATION OF DOMESTIC PARTNERSHIP AFFIDAVIT
(County of Champaign, Illinois)
WE DO HEREBY CERTIFY OURSELVES TO BE DOMESTIC PARTNERS AS DEFINED BY THE
COUNTY OF CHAMPAIGN, ILLINOIS DOMESTIC PARTNER REGISTRY ORDINANCE.
WE FURTHER DECLARE:
• We are engaged in a committed relationship and intend to remain together indefinitely.
• We are at least 18 years of age and have the capacity to enter into a contract.
• We share a common permanent residence and are jointly responsible to each other for the necessities
of life.
• We are not related by blood closer than permitted for married couples under Illinois marriage laws.
• Neither of us has another domestic partner.
• Neither of us is legally married.
• Neither of us may lawfully be claimed as a dependent on any other person’s federal income tax return.
• We understand that the registration of this Domestic Partnership Affidavit creates a domestic
partnership of continuous duration until either of us files an Affidavit of Termination or upon the death
of either of us.
• Each of us agrees to file jointly or separately an Affidavit of Termination with the Insurance
Specialist, Administrative Services, within 30 days of a change in this domestic partnership such that
we no longer meet the criteria herein.
WE CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
Applicant’s signature __________________________
_____________________________
(print)
(written)
Address: (street) ________________________ (city/state) ____________________ zip code ____________
Proof of age verified _____
Applicant’s signature _________________________
_____________________________
(print)
(written)
Address: (street) _______________________ (city/state) ____________________ zip code _____________
Proof of age verified _____
SUBSCRIBED and SWORN to before me by
_______________________ and ________________________
this ________ day of _________, 20_____.
__________________________________________
(Notary Public)
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