Suffolk County Clerk's Office 310 Center Drive, Riverhead, NY 11901 Phone: 631-852-2000 "www.suffolkcountyny.us/clerk" Hours: Mon. - Fri., 9:00 A.M. - 5:00 P.M. Judith A. Pascale Suffolk County Clerk DISSOLUTION OF DOMESTIC PARTNERSHIP AFFIDAVIT I, ____________________________________, certify that I previously filed a Statement (Print) of Domestic Partnership with the County Clerk of Suffolk, New York. I now inform the Suffolk County Clerk that ______________________________ is no longer my Domestic Partner. (Print) I further certify that a signed copy of this Notice of Dissolution of Domestic Partnership has been mailed or otherwise delivered to the Domestic Partner identified above. I understand that I may not file a new Statement of Domestic Partnership Statement for a minimum of six (6) months following the date this Notice of Dissolution of Domestic Partnership has been filed by the County Clerk of Suffolk, New York. ACKNOWLEDGEMENTS: A.) If either party or both parties to a registered domestic partnership determines that the partnership has terminated, one of the partners shall file a termination statement with the Suffolk County Clerk. The person filing the termination statement shall declare that the domestic partnership is terminated and, if the termination statement has not been signed by both domestic partners, that the other domestic partner has been notified. B.) A domestic partnership shall terminate whenever one of the parties to the partnership marries a third party. A domestic partnership shall terminate upon the death of one of the parties. C.) Applicants' Name: 1) __________________________ 2) __________________________ (Print) (Print) Applicants' Signature: 1) __________________________ 2) _________________________ (Signature) (Signature) Address: __________________________________________________________________ STATE OF NEW YORK COUNTY OF SS:} Sworn before me this______ day of________________, 20____. _________________________________ NOTARY PUBLIC American LegalNet, Inc. www.FormsWorkflow.com