This is an editable pdf form. Click the box above to make the form fields visible. Westchester County Clerk Timothy C. Idoni Affidavit of Domestic Partnership Registration We, the undersigned, _______________________________ and ________________________________, Do hereby declare ourselves to be domestic partners. We reside in the County of Westchester, or one of us is employed by the County of Westchester. We are both eighteen (18) years of age or older, unmarried and competent to enter into a contract. We are not related by blood in a manner that would bar marriage under the laws of the State of New York. We share a common household. We are in a close, committed, financially interdependent personal relationship and intend to remain in the relationship. We are each other’s sole domestic partner, have no other domestic partner and intend to remain each other’s sole domestic partner. Neither of us has terminated another domestic partnership within the last sixty (60) calendar days. We agree to file a termination statement in the event that the domestic partnership is terminated. Signature Department (if employed by Westchester County) Signature Address: Department (if employed by Westchester County) Sworn to before me this _____________________ day of ___________________________, 20______. Notary Public FOR OFFICE USE ONLY Registration Number: __________________ Date Filed: ___________________________ The certificate will be issued upon the sworn statement of the applicants, under penalty of perjury, with no liability for the validity of the partnership assumed by the County of Westchester or the County Clerk, in accordance with Chapter 550 of the Laws of Westchester County. Rev. 5/08 American LegalNet, Inc. www.FormsWorkflow.com