Domestic Partnership Affidavit - State Of Illinois

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State of Illinois }
For office use only
County of Cook}
File #
File Date
Cook County Clerk – David Orr
$30 Application Fee
DOMESTIC PARTNERSHIP AFFIDAVIT
WE DO HEREBY CERTIFY OURSELVES TO BE DOMESTIC PARTNERS AS DEFINED BY THE COOK
COUNTY DOMESTIC PARTNERSHIP REGISTRY ORDINANCE. WE FURTHER DECLARE:
We are both 18 years of age or older.
We are both unmarried.
We are both competent to enter into a contract.
We are not related by blood in a manner that would bar marriage under the laws of the State of Illinois.
We share a common household.
We live in Cook County, or one or both of us is employed within Cook County.
We are in a close and committed relationship of mutual financial and emotional support, and intend to remain in the
relationship.
We are each other’s sole domestic partner, have no other domestic partner and intend to remain each other’s sole
domestic partner.
Neither of us has terminated another registered domestic partnership within the last 30 calendar days.
Each of us agrees to file jointly or separately an Affidavit of Termination in the event that the domestic partnership is
terminated.
WE CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
Applicant’s signature ____________________________________
Applicant’s printed name______________________________
Address_______________________________________________
City, State, Zip______________________________________
Date of birth___________________________________________
Employer name (if applicable)_____________________________
Address___________________________________________
Applicant’s signature ____________________________________
Applicant’s printed name______________________________
Address_______________________________________________
City, State, Zip______________________________________
Date of birth___________________________________________
Employer name (if applicable)_____________________________
Address___________________________________________
SUBSCRIBED and SWORN to before me by
_____________________________________________________ and ___________________________________________________
on _______________________________________, 20____
____________________________________________
Notary Public
For office use only – Identification presented
Type_______________________________________________
Type___________________________________________
ID# ________________________________________________
ID#____________________________________________
Type_______________________________________________
Type___________________________________________
ID# ________________________________________________
ID#____________________________________________
Richard J. Daley Center
Cook County Clerk
50 W. Washington - CL25
Chicago, IL 60602
312-603-5664

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