Pinellas County Affidavit Of Domestic Partnership Registration Form (Page 2 of 2) in pdf

PERSON AT ALL TIMES AND PROVIDE THE CLERK OF COURT WITH UP-TO DATE INFORMATION CONCERNING

THE STATUS OF OUR DOMESTIC PARTNERSHIP.

List the name(s) of any dependent(s) that reside(s) within the mutual household of the co-applicants who is

(are): 1) a biological, adopted, or foster child of a domestic partner; or 2) a dependent as defined under IRS

regulations; or 3) a ward of a domestic partner as determined in a guardianship or other legal proceeding; or 4)

a person supported in whole or in part by their registered partner’s earnings and relies on such support.

List Dependents:__________________________________________________________________________

If the above is left blank, it would be automatically assumed that there are no dependents.

We swear or affirm under penalty of perjury that the statements and information provided on this form

are true and correct.

Signed on _________________________in__________________________,________________

Date

City

State

______________________________

____________________________

Signature of Applicant

Witness (may not be blood relative of applicant)

Print Name:__________________________

Date of Birth:___________

______________________________

____________________________

Signature of Applicant

Witness (may not be blood relative of applicant)

Print Name:__________________________

Date of Birth: _____________

Notarization of both signatures: (Required)

State of____________________

County of__________________

Sworn to and subscribed before me this ___ day of ___________, 20__ by

_____________________________ and ________________________________

Who are personally known ____ or produced the following identification ____:

_____________________________________________________________________________.

________________________________________________

Signature of Notary Public

SEAL

NOTE: If either of the co-applicants claims any exemption to public record disclosure pursuant to Section 119, Florida Statutes, the

person claiming such exemption must make a separate written request for maintenance of the exemption as to this record. A form is available

upon request from the Clerk of Court for this purpose.

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Pinellas County Affidavit Of Domestic Partnership Registration Form Page 2