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 STATEMENT OF DOMESTIC PARTNERSHIP AFFIDAVIT WE DO HEREBY CERTIFY OURSELVES TO BE DOMESTIC PARTNERS AS DEFINED BY LOCAL LAW 26-2006 TO AUTHORIZE A COUNTY REGISTRY FOR DOMESTIC PARTNERS. WE FURTHER DECLARE: Either (a) both persons are residents of Suffolk County, or (b) at least one partner is employed by the County of Suffolk on the date of registration; Both persons are eighteen (18) years of age or older and mentally competent to execute a contract; Neither of us is legally married to a third party; Neither of us is a party to another domestic partnership, or has been a party to another domestic partnership within the six months immediately prior to registration; We are not related to each other by blood in a manner that would bar marriage in the State of New York; We have a close and committed personal relationship, live together, and have been living together on a continuous basis for at least one (1) year; and We understand that the registration of this Domestic Partnership Affidavit creates a domestic partnership of continuous duration until an Affidavit of Termination is filed or upon the death or marriage of either of us; and We have submitted at least two (2) items of proof evidencing our financial interdependence as listed in Local Law 26-2006. - - - - WE CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT UNDER PENALTY OF LAW. 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 FOR OFFICE USE ONLY: PLEASE CHECK THE TWO CATAGORIES OF PROOF SUBMITTED AS EVIDENCE BY THE DOMESTIC PARTNERSHIP APPLICANTS : JOINT BANK ACCOUNT - STATEMENT WITH BOTH NAMES - CHECK WITH BOTH NAMES - PASSBOOK WITH BOTH NAMES HEALTH CARE PROXY - COPY OF HEALTH CARE PROXIES/LIVING WILLS, WITH EACH JOINT CREDIT CARD - STATEMENT WITH BOTH NAMES PARTY GIVING THE OTHER PARTY THE POWER TO MAKE HEALTH CARE/NONRESUSCITATION DECISIONS UPON INCAPACITATION JOINT OBLIGORS ON LOAN - NOTE OR OTHER LOAN ORIGINATION DOCUMENT WITH BOTH NAMES LIFE INSURANCE - COPY OF POLICY WITH ONE PARTY NAMING THE OTHER AS BENEFICIARY JOINT OWNERSHIP OF RESIDENCE - DEED OR OTHER SALE/TRANSFER DOCUMENT WITH BOTH NAMES PROPERTY OR WATER TAX DOCUMENT WITH BOTH NAMES RETIREMENT BENEFITS - COPY OF BENEFICIARY DESIGNATION FORM WITH ONE PARTY DESIGNATING THE OTHER AS BENEFICIARY TAX RETURNS JOINT MEMBERSHIP - MORTGAGE AGREEMENT JOINT TENANTS ON LEASE - LEASE WITH BOTH NAMES - CHURCH - FAMILY ORGANIZATION COMMON HOUSEHOLD EXPENSES - UTILITY/TELEPHONE BILL WITH BOTH NAMES REGISTRATION - DOMESTIC PARTNERSHIP FILED IN A DIFFERENT STATE OR MUNICIPALITY WHICH RECOGNIZES SUCH PARTNERSHIPS - PUBLIC ASSISTANCE DOCUMENT WITH BOTH NAMES DAYCARE - JOINT RESPONSIBILITY FOR CHILDCARE AS EVIDENCED BY SCHOOL DOCUMENTS OR GUARDIANSHIP JOINT CUSTODY OF A CHILD JOINT VEHICLE OWNERSHIP -TITLE IN BOTH NAMES JOINT INVESTMENTS - INVESTMENT SECURITIES WITH BOTH NAMES JOINT WILLS - COPY OF WILL OR WILLS, WITH EACH PARTY NAMING THE OTHER AS BENEFICIARY AND/OR EXECUTOR - MUTUAL FUND STATEMENTS WITH BOTH NAMES - BROKERAGE ACCOUNT STATEMENTS WITH BOTH NAMES POWER OF ATTORNEY - COPY OF POWERS OF ATTORNEY WITH EACH PARTY NAMING THE OTHER PARTY AND NO LIMITATION ON THE TERM OF THE DOCUMENTS AFFIDAVIT - BY A CREDITOR OR OTHER PERSON ABLE TO TESTIFY TO PARTNER'S FINANCIAL INTERDEPENDENCE COUNTY CLERK - OTHER PROOF ESTABLISHING ECONOMIC INTERDEPENDENCE, AS DETERMINED BY THE COUNTY CLERK American LegalNet, Inc. www.FormsWorkflow.com