Domestic Partnership Termination Affidavit - City Of Orlando printable pdf download

RECORD & RETURN to:

Amy T. Iennaco

Interim City Clerk

City of Orlando

400 S. Orange Avenue, 2

floor

Orlando, FL 32801

CITY OF ORLANDO AFFIDAVIT OF TERMINATION OF DOMESTIC PARTNERSHIP

Article VI – Chapter 57 of the Orlando City Code

City of Orlando City Clerk 407-246-2251

Office Hours: Monday through Friday from 8:30 a.m. to 4:00 p.m.

Instructions:

Complete and submit this form (notarization is required) to the City Clerk’s Office at the address above. Call the City

Clerk’s office to 1) provide the City Clerk with your current contact information and your former partner’s contact

information and 2) to obtain your City of Orlando Domestic Partnership registration number and Orange County Official

Records information if you do not have it. A filing fee of $10.00 is required and must accompany the registration form. It

may be submitted by mail to the address above or in person to the Orlando City Clerk’s Office. Make check payable to the

City of Orlando. The termination of Domestic Partnership becomes effective on the date of the recording of this form.

State of _____________________________ )

County of ___________________________

)

I swear or affirm under penalty of perjury that:

1. The Domestic Partnership, an affidavit of which was recorded in Orange County Official Record Book ___________

Page ____________, and as City of Orlando Domestic Partnership Registration Number ____________________

between ____________________________________________________________________ (former domestic partner)

and ______________________________________________________________________________ (the undersigned),

is terminated.

2. On _____________________________________________, I provided the City Clerk’s Office with my former partner’s

last known address and I understand that a copy of this Affidavit of Termination of Domestic Partnership will be provided to

my partner to that address and to any email on file with the City Clerk for my former partner.

I understand that the original of this Affidavit of Termination of Domestic Partnership will be recorded in the Orange

County Official Records and that the rights that my former domestic partner and I received as a result of registering our

partnership, including health care surrogacy, are no longer applicable.

Signature

Print Name:

Notarization: (Required)

Sworn to and subscribed before me this _______ day of ________________, 201__, by

who is personally known to me ______ or produced identification

Signature of Notary Public

For Clerk’s Use Only; Filing Date _______

__ Received by __

____________

__________ Registration # DPR-_________________________

Sent to Recording on _______________

___ By: ____________

_____________________

Date of Amendments/Termination

Domestic Partnership Termination Affidavit - City Of Orlando

Related Articles

Related forms

Related Categories