#533 Digna Abello & Ingrid CabreraMIAMIBEACH
533
City Clerk's Office - 1 700 Convention Center Drive, Miami Beach, FL 33139
Phone: 305-673-7411 Email: CityClerk@miamibeachfl.gov - Office Hours: Monday through Friday from 8:30 a.m. to 5:00 p.m.
DECLARATION OF DOMESTIC PARTNERSHIP REGISTRATION FORM
Article IV -Chapter 62-131 of the Miami Beach City Code
Instructions:
Complete and submit this form (notarization is required) to the City Clerk's Office at the address above. A filing fee of $50.00 is required
and must accompany the registration form. Make check payable to the City of Miami Beach.
We the undersigned do declare that we meet the requirements of Section 62-131:
• We are both at least 18 years of age and competent to contract;
• We are not married to or a member of another Registered Domestic Partnership or civil union with anyone other than the co -
applicant;
• We agree to share the common necessities of life and to be responsible for each other's welfare;
• We share a primary residence;
• We consider ourselves to be a member of the immediate family of the other partner;
• We agree to immediately notify the City Clerk's Office, in writing, of any change in the status of the Registered Domestic Partnership;
• We agree to mutually support the other by contributing in some fashion, not necessarily equally to maintain and support the
Registered Domestic Partnership; and
• Each partner agrees to immediately notify the City Clerk's Office, in writing, if the terms of the Registered Domestic Partnership are
no longer applicable or one of the domestic partners wishes to terminate the domestic partnership.
Do you or your domestic partner claim any exemption to public record disclosure pursuant to Section 1 19 Florida Statutes?
Yes ❑ No. If "yes", submit on a separate page a detailed explanation of exemption.
List the name(s) of dependent(s) who reside(s) within the household of the Registered Domestic Partnership and is (are):
1. a biological adopted, or foster child of a Registered Domestic Partner; or
2. a dependent as defined under IRS regulations; or
3. a ward of a Registered Domestic Partner as determined in a guardianship or other legal proceeding.
If the above is Left blank, it would be automatically assumed that there are NO dependents.
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Common Residence Address City State Zip Code
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Mailing Address
Code
'0530'1 003-8
City
State
3385
Zip
Telephone Number
Email (Optional)
We swear or affirm under Penalty of perjury that the statements above are true and correct. f_
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Signature
NotarizationJof both signatures: (Required)
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Sworn to and subbribed before me this ( 1 day of
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Signature of Notary Public
MICHELLE RENEE VIERA
I MY COMMISSION # EE179355
,, EXPIRES March 14, 2016
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For Clerk's Use Only: Filing Date 5/I14/5' MCR#ioY/17 Received by:ergwrbe,,, Registration Number .533