#113 Maynard Cruz & Scott Gray-terminationOTA MIAMI BEACH
City Clerk's Office - 1700 Convention Center Drive, Miami Beach, FL 33139
Phone: 305-673-7411 Email: CityClerk@miamibeachfi.cov - 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. /1',3
Instructions:
Complete and submit this form (notarization is required) to the City Clerk's Office at the address above. A filing fee
of $25.00 is required and must accompany the registration form. Make check payable to the City of Miami Beach.
The termination of Domestic Partnership becomes effective on the date of filing this form. This form to be
used only when signed by one partner.
Do you or your domestic partner claim any exemption to public record disclosure pursuant to Section 119
Florida Statutes? ❑ Yes 0 No. If "yes'; submit on a separate page a detailed explanation of exemption.
I swear or affirm under penalty of perjury that:
1. The Domestic Partnership between
Registration Number
cc/
Former Domestiartner
, and the undersigned, is hereby terminated, and
2. On , the City Clerk's Office was provided with his/her last known
address, which is 9' O 1e s �Cz. �`����''' rr "`� � %' . A copy of
2y /-/ or- J h' i6j 33) Gei
the termination statement shall be served by certified or registered mail on the other Registered
Domestic Partner.
Signature
Print Name / / J,4 ►2 (ire:4
Address: c9 / �' � r,� `/� c2 647 eC 4 Z f 2 33/r7)
Telephone Number (j) 3g/
Notarization: (Required)
State of
County of
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Sworn to and subscribed before me this (DD. day of ;AU
,20AK by M
who are personally known r produced Identificat o
ig ature of otar''ublic
For Clerk's Use nly:
Filing Date
:,•;
FERNANDA SILVA
='- r MY COMMISSION # GG 230013
EXPIRES
�;r %.►1`+P:c�' :August27, 2022
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