State of California Secretary of State Confidential Declaration of Domestic Partnership C FILE NO:____________________ This Space For Filing Use Only IMPORTANT ­ Read instructions before completing this form. We the undersigned, do declare that we have been living together as domestic partners and meet the requirements of Family Code section 297, which are as follows: Neither person is married to someone else or is a member of another domestic partnership with someone else that has not been terminated, dissolved, or adjudged a nullity. The two persons are not related by blood in a way that would prevent them from being married to each other in this state. Both persons are at least 18 years of age, OR if one or both persons are under 18 years of age, a certified copy of the court order(s) granting permission to the underage person(s) to establish a domestic partnership is attached. Both persons are members of the same sex, OR one or both of the persons is over 62 years of age and one or both meet the eligibility criteria under Title II of the Social Security Act as defined in United States Code, title 42, section 402(a) for old-age insurance benefits or Title XVI of the Social Security Act as defined in United States Code, title 42, section 1381 for aged individuals. Both persons are capable of consenting to the domestic partnership. Both persons consent to the jurisdiction of the Superior Courts of California for the purpose of a proceeding to obtain a judgment of dissolution or nullity of the domestic partnership or for legal separation of partners in the domestic partnership, or for any other proceeding related to the partners' rights and obligations, even if one or both partners ceases to be a resident of, or to maintain a domicile in, this state. The representations are true and correct, and contain no material omissions of fact to the best of our knowledge and belief. Filing an intentionally and materially false Declaration of Domestic Partnership (Confidential) shall be punishable as a misdemeanor. (Family Code section 298(c).) PARTNER 1 ___________________________________________________________ PARTNER 2 ___________________________________________________________ Printed Name (Last) (First) (Middle) Printed Name (Last) (First) (Middle) ___________________________________________________________ ___________________________________________________________ Signature of Partner as Stated Above OPTIONAL Name Changes: New Last Name_______________________________________ New Middle Name _____________________________________ Date of Birth (required for name change) ___________________ Signature of Partner as Stated Above OPTIONAL Name Changes: New Last Name_______________________________________ New Middle Name ____________________________________ Date of Birth (required for name change) ___________________ Mailing Address City State Zip SEC/STATE NP/SF DP-1A (Rev 04/2015) (Page 1 of 2) ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of _____________________________) On _________________________ before me, _________________________________________ (insert name and title of the officer) personally appeared ______________________________________________________________, 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(ies), 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 official seal. Signature ______________________________ (Seal) SEC/STATE NP/SF DP-1A (Rev 04/2015) (Page 2 of 2) Instructions for Completing the Confidential Declaration of Domestic Partnership (Form NP/SF DP-1A) For easier completion, this form is available on the Secretary of State's website at www.sos.ca.gov/registries/domesticpartners-registry/. It can be viewed, filled in and printed from your computer. If you do not complete this form online, please type or legibly print in black or blue ink. Do not alter this form. Statutory filing provisions are found in California Family Code sections 297 and 298. All statutory references are to the California Family Code, unless otherwise stated. Complete the Confidential Declaration of Domestic Partnership (Form NP/SF DP-1A) as follows: Both persons must be living together as domestic partners and meet all of the requirements of Section 297, as stated on the front of the Confidential Declaration of Domestic Partnership form. Both persons must sign and affix their signatures to the same Confidential Declaration of Domestic Partnership form. Both persons must print their names legibly. The names must be printed in the order requested: Last name, First name, Middle name. If there is a suffix, i.e. Jr., Sr., etc., include this as part of the last name. One or both persons to a registered domestic partnership may change the middle or last names by which that person wishes to be known after registration of the domestic partnership by entering the new name and including their date of birth in the spaces provided on the Confidential Declaration of Domestic Partnership form. A person may adopt any of the following middle or last names: the current last name of the other domestic partner; the last name of either domestic partner given at birth; a name combining into a single last name all or a segment of the current last name or the last name of either domestic partner given at birth; or a hyphenated combination of last names. (Section 298.6.) A complete mailing address is required (address, city, state, zip code.) Print legibly. Do not abbreviate city names. The signature of both persons must be notarized with a certificate of acknowledgment. The Confidential Declaration of Domestic Partnership must be signed using the name of the individual prior to the name change, if any, listed on this form. The completed form can be mailed to Secretary of State, Domestic Partners Registry, P.O. Box 942870, Sacramento, th nd CA 94277-2870 or