#231 Barbara Suzanne Cooper & Michelle Heinrich •
MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK'S OFFICE
Tel: 305-673-7411 , Fax: 305 -673 -7254
I 17, ��
July , 2008 j ` 1
�I
Barbara Suzanne Cooper
5000 Western Avenue, #1402
Knoxville, TN 37921
Dear Barbara:
This office is in receipt of a Declaration of Termination of Domestic Partnership form
(Registration Number 231).
According to Ordinance No. 2004 -3451, the enclosed form requires your signature. Upon
signing the form, please return to the City Clerk's Office to the address above. The termination
becomes effective on the date of filing of the termination statement signed by both Registered
Domestic Partners or on the date proof of service is filed with the City Clerk's Office pursuant to
subsection (c) (1)b .
If you have any questions please do not hesitate to contact our office at any time.
Sincerely,
Liliam Hatfield
Office Association V
LH
F: \CLER\$ALL\DOMESTIC PARTNERSHIP \Miscellaneous \231 Termination Ietter.doc
We are committed to providing excellent public service and safety to all who live, work, and play in our vibrant, tropical, historic community.
MIAMI BEACH
•
City Clerk's Office - 1700 Convention Center Drive, Miami Beach, FL 33139
Phone: 305 - 673 -7411 Email: CitvJClerk(a miamibeachfl.c ov - Office Hours: Monday through Friday from 8:30 a.m. to 5:00 p.m.
DECLARATION OF TERMINATION OF DOMESTIC PARTNERSHIP
Article IV - Chapter 62 -131 of the Miami Beach City Code
Registration No. .- 3 1
xj
Instructions:
r
Complete and submit this form (notarization is required) to the City Clerk's Office at the address above. A- flung Q
of $25.00 is required and must accompany the registration form. Make check payable to the City of lianti- .Bea6Fiif
The termination of Domestic Partnership becomes effective on the date of filing this form. Thw forte to
used only when signed by one partner. ca
Do you or your domestic part r claim any exemption to public record disclosure pursuant to S tiorj19
l
Florida Statutes? ❑ Yes NI No. If "yes ", submit on a separate page a detailed explanation of exenrition.
I swear or affirm under penalty of perjury that:
1. The Domestic Partnership between Cw b 'CiY'c S r✓( za n n Ce o r
Former Domestic Partner
Registration Number 2 - 3 , and the undersigned, is hereby terminated, and
2. On / O si /y 2 0 0 3 , the City Clerk's Office was provided with his /her last known
address, which is 7000 W e I
�Q -I` Ave.' ., �� • � l�' a L �Y6�X V r � � � . A copy of
3° 7 21
the termination statement shall be served by certified or registered mail on the other Registered
Domestic Partner.
Signature
Print Name / d e r - i � • • • • • • • • • •
• • • • • • • • •
•
Address: 1612- - (1 Va. D. , i4i i vI ((Q ) 7 37 z �►p' (4.
STATE
Telephone Number 2q S-2400 oF
O
TENNESSEE•: : • : •
NOTARY . .... • •
Notarization: (Required) PUBLIC
State of _ !1/ /j4 .G t
l' ( �0+
ilyv
County of l l
Sworn to and �' � 2 � >� ciS
d subscribed before me this �� day of J , 2001 by ���1 �h0,ili A
a nd
who are personally known or produced Identification 77Jf)1 U 9,9Q/e7/5 .
L 'i / • i / MY COMMISStc>n' >" xpimFS MARL
Signature of Notary Public MARCH 3 , 20'12 -
For Clerk's Use Only:
Filing Date a MCR#er ,-- Received by: ?L&11'
F:\CLER \$ALL\DOMESTIC PARTNERSHIP \Registration Packet Forms \DRAFT- Terminationl declaration . new Iogo.doc