Revised 5/26/17 Declaration of Domestic Partnership RETURN TO: INSTRUCTIONS Comp lete the following information t o declare a d omestic p artnership . AFFIRMATION We swear or affirm under penalty of perjury that: 1. We are residents of Palm Beach County; 2. We are both at least eighteen (18) years old and competent to contract; 3. We are not married to each other or anyone else; 4. We are the sole domestic partner of the other person; 5. We are not related to the other by blood; 6. We consent to the domestic partnership relationship without force, duress or fraud; 7. of life and welfare; 8. We have not been a member of another domestic partnership for the past year; 9. We share our primary residence with each other; 10. We consider ourselves to be a member of the immediate family of each other; 11. We share financial responsibilitie s as domestic partners; and that 12. The name and mailing addresses of each domestic partner are: Partner 1: Printed Name: Address: City: State: Zip: Partner 2 : Printed Name: Address: City: State: Zip: DOCUMENTATION The documentation as indicated below is provided with this declaration. Copies may be presented in lieu of originals. Documentation will be returned to you. Please check those items presented. To establish mutual residence, one (1) of the following must be presented: Current mortgage, deed or lease showing both names Current tax returns showing the same address for both partners Current government issued photo identification showing the same address for both partners Revised 06/22/2004 Revised 06/22/2004 Revised 06/22/2004 American LegalNet, Inc. www.FormsWorkFlow.com Revised 5/26/17 To establish joint financial responsibility, two (2) of the following must be presented: Current mortgage, deed or lease showing both names Current statement from joint bank account Current credit card statement with same account number for both names Vehicle title showing common ownership A beneficiary designation form for a retirement plan or life insurance policy signed and completed to the effect that one domest ic partner is the beneficiary of the other Wills designating the other as primary beneficiary STATEMENT Acknowledgement: I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this petition and that the punishment for making a false statement includes fines and/or imprisonment. Signature: Date: Printed Name: Address: City: State: Zip: STATE OF FLORIDA COUNTY OF PALM BEACH Sworn or affirmed and signed before me on by Notary Public or Deputy Clerk of Court [Print, type or stamp commissioner name of notary or clerk] Deputy Clerk Signature and Seal Acknowledgement: I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this petition and that the punishment for making a false statement includes fines and/or imprisonment. Signature: Date: Printed Name: Address: City: State: Zip: STATE OF FLORIDA COUNTY OF PALM BEACH Sworn or affirmed and signed before me on by Notary Public or Deputy Clerk of Court [Print, type or stamp commissioner name of notary or clerk] Deputy Clerk Signature and Seal American LegalNet, Inc. www.FormsWorkFlow.com