#533 Digna Abello & Ingrid Cabrera(1)1
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CITY OF MIAMI BEACH EMPLOYEE
TERMINATION OF DOMESTIC PARTNERSHIP STATEMENT
Per the Domestic Partnership Ordinance, No. 98-3127, and as specified in the Declaration of Domestic
Partnership, within 30 days of termination of Domestic Partnership, the Domestic Partner(s) MUST fie this
document with the Human Resources Department (located on the 3rd floor of City Hall, 1700 Convention
Center Drive). The fee for registering or terminating the Domestic Partnership is twenty-five dollars ($25).
I, � a , previously the Domestic Partner of in4 eelpr .
ow and affirm under penalty of perjury that tl
a. the Domestic Partnership is terminated; and
b. if the Termination Statement is not signed by both Partners, a copy of the Termination Statement shall be
served, by the Partner filing the Termination Statement, by certified or registered mall. on the other
Domestic Partner, and proof of service shall he filed with the Human Resources Department.
This Termination shall become effective sixty (60) days from the date of filing of the Termination Statement
signed by both Domestic Partners or if the Termination Statement is not signed by both parties, sixty (60)
days from the date proof of service is filed with the Human Resources Department pursuant to Section 2(a)(2)
of the Domestic Partnership Ordinance. A Domestic Partnership shall automatically terminate In the event
that one of the Domestic Partners enters into a Domestic Partnership with another individual, marrtea,
remarries, or dies.
nowt: +ge that l have read, understood, and agree to compleetiitlh the terns of this document.
PLO DOMESTIC PARTNER)
're of CITY EMPLOYEE)
(Address)
03. WEN,.
(bete of Birth) (City Employee ID #)
and
t
(Address)
(Date of Birth) (ID #, if City Employee)
------- DO N0iWRITE BELOW THIS LINE — FOR HUMAN RESOURCES DEPARTMENT USE ONL
The above Termination of Domestic Partnership Statement was approved by the Human R
partmont. Per Ordinance No. 98-3127, the termination shall become effective on the date entered
De vetoped
MICHELLE ME
Notary Public - State o
Commission 0 ff
My Comm. Expires M