Declaration Of Domestic Partnership - City Of Cleveland Heights - 2011
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1CITY OF CLEVELAND HEIGHTS
# _______ – 2011
40 SEVERANCE CIRCLE
CLEVELAND HEIGHTS, OHIO 44118
DECLARATION OF DOMESTIC PARTNERSHIP
The undersigned hereby declare, under penalty of perjury, the following to be true at the time of signing
this form:
1. We share a common residence as defined in Chapter 181 of the Cleveland Heights Codified Ordinances.
2. We agree to be in a relationship of mutual interdependence as defined in Chapter 181 of the Cleveland
Heights Codified Ordinances.
3. Neither of us is married to a third individual or a member of a civil union or domestic partnership
with a third individual.
4. Each of us is 18 years of age or older.
5. We are not related by blood in a way that would prevent us from being married to one another in this state.
6. We agree to file a Declaration of Domestic Partnership with the City.
7. We understand that no individual who has previously filed a Declaration of Domestic Partnership in
this city may file a new Declaration of Domestic Partnership until at least 90 days after the date that
a Notice of Termination of Domestic Partnership was filed with the City under this Ordinance (unless
one of the D omestic Partners has died).
8. Our common residence and mailing address is:
__________________________________________ ____________________________________________
Street Address
City, State, Zip
_____________________________
Phone
Domestic Partner
Domestic Partner
____________________________________________
____________________________________________
Signature
Signature
____________________________________________ _________________________________________
Print Name
Print Name
STATE OF OHIO
)
) ss:
COUNTY OF CUYAHOGA
)
Before me, a Notary Public in and for said county, personally appeared _________________________
and ___________________________, who acknowledged that they did sign the aforesaid instrument and the
same is their free act and deed.
In testimony whereof, I have hereunto set my hand and official seal at Cleveland Heights, Ohio this
________ day of _________________, 2011.
_______________________________________________
Notary Public
– This document will be kept on file at the City of Cleveland Heights, Ohio. –
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