Application For Registration As A Domestic Partnership Form

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OFFICE USE ONLY
Date Received _____________
Effective Date _____________
APPLICATION FOR REGISTRATION AS A DOMESTIC PARTNERSHIP
REGISTRATION FEE: $50.00
We hereby apply to register as Domestic Partners (each applicant initial).
I have read and understand the terms and conditions of Chapter 5 of the St. Louis Park
_____ _____
City Code attached to this application.
I affirm that we meet the definition of Domestic Partners and are eligible for registration.
_____ _____
APPLICANT INFORMATION
PRINT NAME:
Date:
_____________________________________________________
SIGNATURE:
PRINT NAME:
Date:
_____________________________________________________
SIGNATURE:
______________________________________________________________________
ADDRESS:
_________________________________________________________________________
CITY/STATE:
Zip:
______________________________________________________
_____________
REGISTRATION REQUIREMENT (please check one):
Reside in St. Louis Park
or
Work in St. Louis Park
STATE OF MINNESOTA
COUNTY OF ___________________
The foregoing instrument was acknowledged and signed before me this _____ day of ____________ , 20__
by ________________________________ and _________________________________ .
Applicant Name
Applicant Name
__________________________________
Notary Public
My Commission expires on __________
(Seal)
The City of St. Louis Park authorizes and establishes a voluntary program of registration of domestic
partners. The domestic partnership registry is a means by which unmarried, committed couples who
reside or work in St. Louis Park and who share a life and home together may document their relationship.
St. Louis Park’s Domestic Partnership ordinance is a City ordinance and does not create rights,
privileges, or responsibilities that are available to married couples under state or federal law. The City of
St. Louis Park cannot provide legal advice concerning domestic partnerships. Applicants and registrants
may wish to consult with an attorney for such advice including but not limited to: wills, medical matters,
finances and powers of attorney, children and dependents, health care and employment benefits.
Mail application and registration fee to: City of St. Louis Park - City Clerk
5005 Minnetonka Blvd
St. Louis Park, MN 55416
Forms must be complete along with notarized signatures to process the application. Fee is required prior
to processing. Questions? Contact the City Clerk at 952-928-2840 or .

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