Domestic Partnership Declaration Form - City Of Urbana, Illinois

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DECLARATION OF DOMESTIC PARTNERSHIP
[City of Urbana, Illinois]
I, _____________________
I,___________________ DO HEREBY DECLARE
AND
that we have thoroughly read and fully understand this Declaration and the Domestic
Partnership Registry Ordinance (attached hereto and made a part thereof) upon which it is
based, and that we are in full compliance with all the requirements for a domestic
partnership and that we hereby declare under oath to be DOMESTIC PARTNERS as
defined in An Ordinance Establishing A Domestic Partner Registry, and enacted pursuant
to a roll call vote of the Urbana City Council as Ordinance No. 2005-04-061.
WE FURTHER DECLARE, as domestic partners, that we have chosen to share one
another’s lives in an intimate and committed relationship of mutual caring and that we are
jointly responsible and obligated for the necessities of life incurred during our domestic
partnership.
THE UNDERSIGNED HEREBY AUTHORIZE the City Clerk, pursuant to Ord. No.
2005-04-061, to file and maintain this original Declaration of Domestic Partnership and
to record the Domestic Partnership evidenced by this Declaration in the Registry of
Domestic Partnerships maintained by the City of Urbana and to make available for public
inspection upon request of such Declaration of Domestic Partnership and the Registry of
Domestic Partnership in which said Declaration is recorded. All portions of the
Domestic Partnership Registry are public information.
THE UNDERSIGNED FURTHER AUTHORIZE the City of Urbana acting pursuant
to Ord. No. 2005-04-061 to issue certified copies of said Declarations to members of the
public upon request and payment of the required fees as required under the Freedom of
Information Act.
THE UNDERSIGNED AGREE to file an Affidavit of Termination of Registered
Domestic Partnership within 30 days of any change in the partnership which causes it not
to satisfy any one of the requirements for a domestic partnership as set forth in Ord. No.
2005-04-061 of the City of Urbana.
THE UNDERSIGNED UNDERSTAND that any person, including any employer, who
relies upon a registered Declaration of Domestic Partnership to the person’s or
employer’s detriment as a result of a false statement contained therein or a false assertion
of family membership; or as a result of a failure to notify the City Clerk, or any person or
employer previously notified of the Domestic Partnership of a change in the status of the
Domestic Partnership or family membership, shall have the right to bring a civil action in
any court of competent jurisdiction against the appropriate Domestic Partner(s) to recover
damages for such detrimental reliance.
THE UNDERSIGNED FURTHER UNDERSTAND that the execution of this
Declaration may further be construed by a court of law as creating enforceable, legal
obligations between the persons executing the same.

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