Registration Of Domestic Partnership Affidavit Form - City Of Urbana, Illinois printable pdf download

Registration Of Domestic Partnership Affidavit Form - City Of Urbana, Illinois

For office use only

Identification Presented:

File #_________________

Type: ____________ ; ID# ________________________

File Date______________

Type: ____________ ; ID# ________________________

Registration Fee ($25.00 cash): ________________

REGISTRATION OF DOMESTIC PARTNERSHIP AFFIDAVIT

[City of Urbana, Illinois]

WE DO HEREBY CERTIFY OURSELVES TO BE DOMESTIC PARTNERS AS DEFINED BY

THE CITY OF URBANA DOMESTIC PARTNER REGISTRY ORDINANCE. WE FURTHER

DECLARE:

We are engaged in a committed relationship and intend to remain together indefinitely.

We are at least 18 years of age and have the capacity to enter into a contract.

We share a common permanent residence and are jointly responsible to each other for the

necessities of life.

We are not related by blood closer than permitted for married couples under Illinois marriage

laws.

Neither of us has another domestic partner.

Neither of us is legally married.

Neither of us may lawfully be claimed as a dependant on any other person’s federal income tax

return.

We understand that the registration of this Domestic Partnership Affidavit creates a domestic

partnership of continuous duration until either of us files an Affidavit of Termination or upon the

death of either of us.

Each of us agrees to file jointly or separately an Affidavit of Termination with the Urbana City

Clerk within 30 days of a change in this domestic partnership such that we no longer meet the

criteria herein.

WE CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT.

Applicant’s

signature ___________________________

____________________________

(printed)

(written)

Address: (street)______________________ (city/state) ____________________ (zip)_________

____

Proof of Age Verified |____|

Phone No: _________________________________

Applicant’s

signature ___________________________

___________________________

(printed)

(written)

Address ____________________________ (city/state) ____________________ (zip)_________

____

Proof of Age Verified |____|

Phone No: _________________________________

SUBSCRIBED and SWORN to before me by

_______________________ and _____________________

_________________________________

this ________ day of__________, 20______.

(Notary Public)

Registration Of Domestic Partnership Affidavit Form - City Of Urbana, Illinois

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