Cristina Ugalde & Tina Dibiase #235 TERMINATIOND MIAMIBEACH
City Clerk's Office - 1700 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 TERMINATION OF DOMESTIC PARTNERS+GElvED
Article IV -Chapter 62-131 of the Miami Beach City Code o APR 02 2024
Reosratoo. 15
CITY OF MIAMI BEA CH
Instructions: OFFICE OF THE CITY CLERK
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 elaim any exemption to public record disclosure pursuant to Section 119
Florida Statutes? []Yes )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] Dibis.
Former Domestic Partner
Registration Nome, Z_5 , and the undersigned, is hereby terminated, and
2 o /2/2 , the City Clerk's Office was provided with his/her last known
address, which is 5344 o . 2o lae HialdhfE 35ore .A copy of
I
the termination statement shall be served by certified or registered mail on the other Registered
. Domestic Par~,,.~
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04/02/2024 03:42PM Carmen W. z%
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Reference MCR433234 m ts ( 1: t) x° n >
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Paid by: CRISTINA UGALDE x n "', In CO
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