Form Lp/sf Dp-1 - Declaration Of Domestic Partnership Page 2
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FILE NO: ____________________
Kevin Shelley
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DECLARATION OF DOMESTIC PARTNERSHIP
(Family Code Section 298)
Instructions:
1.
Complete and mail to: Secretary of State, P.O. Box 942877,
Sacramento, CA 94277-0001 (9l6) 653-4984
2.
Include filing fee of $10.00. Make check payable to Secretary of State.
We the undersigned, do declare that we meet the requirements of
(Office Use Only)
Section 297 at this time:
We share a common residence;
We agree to be jointly responsible for each other’s basic living expenses incurred during our domestic partnership;
Neither of us is married or a member of another domestic partnership;
We are not related by blood in a way that would prevent us from being married to each other in this state;
We are both at least 18 years of age;
We are both members of the same sex or one/or both of us is/are over the age of 62 and meet the eligibility criteria under Title II
of the Social Security Act as defined in 42 U.S.C. Section 402(a) for old-age insurance benefits or Title XVI of the Social Security
Act as defined in 42 U.S.C Section 1381 for aged individuals;
We are both capable of consenting to the domestic partnership;
Neither of us has previously filed a Declaration of Domestic Partnership with the Secretary of State pursuant to Division 2.5
of the Family Code that has not been terminated under Section 299 of the Family Code.
The representations herein are true, correct and contain no material omissions of fact to our best
knowledge and belief. Sign and print complete name.
(If not printed legibly, application will be rejected.)
Signatures of both partners must be notarized.
_____________________________________
______________________________________________________
Signature
(Last)
(First)
(Middle)
_____________________________________
______________________________________________________
Signature
(Last)
(First)
(Middle)
___________________________________________________________________________________________________
Common Residence Address
City
State
Zip Code
___________________________________________________________________________________________________
Mailing Address
City
State
Zip Code
NOTARIZATION IS REQUIRED
State of California
County of _____________________________
On
, before me,
, personally
appeared
personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) are subscribed to
the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that
by his/her/their signature(s) on the instrument the person(s) executed the instrument.
_______________________________________________
[
Signature of Notary Public
PLACE NOTARY SEAL HERE]
SEC/STATE LP/SF DP-1 (Rev 01/2003)
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