Domestic Partnership Declaration Form - City Of Urbana, Illinois (Page 2 of 2) in pdf

Domestic Partnership Declaration Form - City Of Urbana, Illinois Page 2

Executed, this ________ day of _____________, ______________.

(month)

(year)

______________________________ and _______________________________

Name of Domestic Partner

______________________________

_______________________________

Proof of Age Verified

______________________________

_______________________________

Address

______________________________

_______________________________

Signature

STATE OF ILLINOIS

)

) SS

COUNTY OF CHAMPAIGN )

I, ________________________, a Notary Public in and for said County, in the State of

Illinois, DO HEREBY CERTIFY that ___________________ and _________________

personally known to me to be the same persons whose names are subscribed to the

foregoing Declaration appeared before me this day in person and each person

acknowledged that they signed and delivered the said instrument as a free and voluntary

act for the uses and purposes therein set forth.

Given under my hand and Notary Seal this __________ day of ____________

(month)

___________

(year)

My commission expires:

______________________________

Notary Public

Domestic Partnership Declaration Form - City Of Urbana, Illinois Page 2