Pinellas County Affidavit Of Domestic Partnership Registration Form printable pdf download

PINELLAS COUNTY AFFIDAVIT OF DOMESTIC PARTNERSHIP

REGISTRATION FORM

§ 70-237 of the Pinellas County Code

Instructions:

Both partners and two (2) witnesses must complete and submit this form (notarization is required) to the Clerk

of the Court (with proof of identification) at one of the four following locations:



Clearwater Courthouse - 315 Court St., Room 150, Clearwater, FL 33756;



North County Branch Office - 29582 U.S. 19 N., Room 101, Clearwater, FL 33761



St Petersburg Branch Office - 545 First Ave. N., Room 153, St Petersburg, FL 33701



Clerk's Tyrone Branch Office - 1800 66th St. N., St Petersburg, FL 33710

Clerk of Court Office Hours: Monday through Friday from 8:00 a.m. to 5:00 p.m., excluding holidays.

A filing fee of $50.00 is required and must be remitted to the Clerk of Court at the time of application.

We, the undersigned co-applicants, do declare that we meet the requirements of Section 70-237(d) of the

Pinellas County Code and agree to the following statements:

Initials of partners

______

*I am at least eighteen (18) years of age and competent to contract.

*I am not married under the laws of the State of Florida, nor am I a partner in a domestic

partnership relationship or a member of a civil union with anyone other than the co-

______

applicant.

______

*I am not related to my co-applicant by blood as defined in Florida Law.

*I consider myself to be a member of the immediate family of the co-applicant and I am

______

jointly responsible for the maintenance and support of the domestic partnership.

______

*I acknowledge that I reside in mutual residence with my co-applicant.

*I designate the co-applicant to act as my healthcare surrogate as provided in Chapter 765,

______

Florida Statutes and as my agent to direct the disposition of my body after death.

______

*I agree to be responsible for the basic food and shelter of my co-applicant.

*In the event that I have been determined incapacitated, I designate the co-applicant as my

______

preneed guardian as defined in Chapter 744, Florida Statutes.

*I agree to immediately notify the Clerk of Court’s Office, in writing, if the terms of the

______

Registered Domestic Partnership are no longer applicable or if one of the domestic partners w

to terminate the domestic partnership.

________________________________________________________________________________________

Mailing Address for Domestic Partners

City

State

Zip

WE UNDERSTAND THAT THIS AFFIDAVIT FORM AND OUR DOMESTIC PARTNERSHIP REGISTRATION

INFORMATION IS A PUBLIC RECORD UNDER FLORIDA LAW. WE UNDERSTAND THAT THE CLERK OF COURT IS

RESPONSIBLE ONLY FOR MAINTAINING THE DOMESTIC PARTNERSHIP REGISTRY. WE UNDERSTAND THAT

THIS FORM DOES NOT CONSTITUTE A “LIVING WILL” AS THAT TERM IS DEFINED IN SECTION 765.101, FLORIDA

STATUTES. WE ACKNOWLEDGE THAT THIS DOMESTIC PARTNERSHIP REGISTRATION IS VALID IN PINELLAS

COUNTY, FLORIDA, AND MAY NOT BE ACCEPTED IN OTHER JURISDICTIONS.

WE ACKNOWLEDGE,

THEREFORE, THAT THIS DOMESTIC PARTNERSHIP REGISTRY MAY NOT CONSTITUTE A HEALTHCARE

SURROGATE OR PRE-NEED GUARDIANSHIP OUTSIDE PINELLAS COUNTY. WE ACKNOWLEDGE THAT THIS

DOMESTIC PARTNERSHIP REGISTRY DOES NOT SUBSTITUTE FOR A POWER OF ATTORNEY. WE

ACKNOWLEDGE THAT IT IS OUR DUTY TO KEEP DOMESTIC PARTNERSHIP DOCUMENTATION ON OUR

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Pinellas County Affidavit Of Domestic Partnership Registration Form

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