#564 Lydia A Mendez & Jose Antonio EspinosaMIAMIBEACH
City Clerk's Office - 1700 Convention Center Drive, Miami Beach, FL 33139
Phone: 305-673-741 1 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 -Section 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 of the Miami Beach City
Code:
❖ 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Domestic Partnership are no longer applicable or one of the domestic partners wishes to terminate the domestic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.
Are you a current City of Miami Beach Employee? ❑Yes
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Common Residence Address City State Zip Code
Mailing Address
7 6- 31—
Telephone Number
City
State Zip Code
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/ Email (Optional)
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NOTE: Please provide the City Clerk's Office with a copy of your ID to ensure your Certificate has the correct
name spelling.
Page 1 of 2
Continued on next page
Do you or your domestic partner claim any exemption to public record disclosure pursuant to Section 119 Florida
Statutes? ❑ Yes )4 No. If "yes", submit a detailed explanation of exemption.
List the name(s) of dependent(s) who reside 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.
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r or affirm under penalty of perjury that the statements above are true and correct.
Signature
Notarization of both signatures: (Required)
State of
County of1�
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(Print egibIy)) Last F rst iddle
(Print legibly) Last First Middle
Sworn to and subscribed before me this /6 day of 19dCZei , 2012 by dig 4. NeJejez
andc:._lp, .,4,+tJ)/Vio �'S'if. t L who are personally known or
produced Identification
Signature ¢f Notary Pu
ISABEL SATCHELL
• ; 3 MY COMMISSION* GG 054808
r' EXPIRES: April 13, 2021
,•8..".;.t°•' Bonded Thru Notary Public Underwriters
For Clerk's Use Only:
Filing Date [o//249t7MCR# 1 t 71,9
Received by: 2., .T a- r
Registration Number 56 L7 Entered By "TiH.�s� 4 Date /0/1:6 /zG l?
Page 2 of 2
F:\CLER\$ALL\DOMESTIC PARTNERSHIP\FORMS\Domestic Partnership Registration Form.Doc