#113 Maynard Cruz & Scott GrayCity of Miami Beach - City Clerk's Office
1700 Convention Center Drive, Miami Beath, FL 33139
Phone: 305-673-7411 Email: CityClerkc miamibeachfl.gov
Office Hours: Monday through Friday from 8:30 a.m. to 5:00 p.m.
2003
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;
•b 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
•A 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Partnership are no longer applicable or one of the domestic partners wishes to terminate the domestic partnership.
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 Regi tered Domestic Partner as determined in a guardianship or her legal proceeding.
(1)
(2)
(3)
(4)
Do you or your domestic partn r claim any exemption to public record disclosure pursuant to Section 119
Florida Statutes? 0 Yesi NNo. If "yes'; submit on a separate age a detailed explanation of exemption.
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Sign
Notarizatio
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Ignature of Notary Pubic
For Clerk's Use Only:
Filing Date // /D S CR# 1,2, Received b
Registration Number 1' tk
The Sunshine State --
LICENSE NUMBER
C620-553-78-051-0
MAYNARD MALLARI CRUZ
NINE ISLAND VE 1914
MIAMI BEACH, FL 33139-0000
BIRTH DATE SEX. HOT, REST. ENDORSE,
02-11-78 M 6.00
ISSUED EXPIRES DUPLICATE
02-12-04 02.1111 00-0040
120128 SAFE DRIVER
Operation of a motor vehicle constitutes consent to any sobriety test required by late.
— The Sunshine State --•
LICENSE NUMBER
G600-790-59-185-0
SCOTT JOSEPH GRAY
NINE ISLAND AVE N1914
MIAMI BEACH, FL 33130439/
BIRTHDATE S6%. HOT. REST,
05-25.69 M 0.02
ISSUED EXPIRES
1219.01 002507
X9902Oe9a N DONOR
t of a motor vehicle cohstitutes consent to any sobriety test requited by taw.
ENDORSE.
DUPLICATE [
00.1902