Domestic Partner Form Western Health Advantage (Page 2 of 2) in pdf

Domestic Partner Form Western Health Advantage Page 2

Non-Registered Domestic Partner Form

Notary Information

California All-Purpose Acknowledgment

State of

____________________________________________

County of

____________________________________________

On __________________________________________ before me, ___________________________________________

date

name & title of ofﬁ cer

personally appeared __________________________________________________________________________________

name(s) of signer(s)

who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is / are subscribed to the within

instrument and acknowledged to me that he / she / they executed the same in his / her / their authorized capacity, and that by his

/ her / their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the

instrument.

I certify under PENALTY of PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.

WITNESS my hand and ofﬁ cial seal.

___________________________________________________________________

SIGNATURE OF NOTARY

NOTARY SEAL

Page 2 of 2

Domestic Partner Form Western Health Advantage Page 2