#259 Florence E. Crosby & Jay C. Adamsz
V
Q
w
m
Q
•,
~,
W
~~
~...,
• «~
~~
.~
J~
.~ },
L
U
O
,~.+ .cn
F-
•~
0
N
O
L
^
v
• ~
H
'a
a
~,
,~
ca
~ rd
4... 'a
~ O
U ~,.-
O
~ ~
~ N
~ ~
L. .1..J
^C
I..L
U ~
c'~i~ U
~ ~
O rya
~ ~
~ ~
~~
~ ~
.~
fB
n
O
O
N
i
~.±
V
O
s
0
.a
ro
D
~3
U
U
L
a
LLi
a~
L
3 ~
O ~
m O C_
~ ~ ~ ~
O N ~O cn
N (~U cn~ J
L= ~ O(~~~
N Off- ~t0
~ ~ ~ U ~ ~ u_
N ~ (n ~ (n n ~
L L L L L L
C
~> 0 0 0 0 0 0
~ ~_ N_ c~_ c~_ cc NN_
L ~~ C C C C
X 0 0 0 0 0 0
U U U U U U
rn
N
O
Z
O
~+
ra
O
U
N
N
N
C
C7 ~
~ ~
O O
C O
Q
~~
U U
City Clerk's Office - 1700 Convention Center Drive, Miami Beach, FL 33139
Phone: 305-673-7411 Email: CitvClerk(c~miamibeachfl.gov
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. ~~~
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
,:ah~e ~::.`t :-c't"e•"= am gs~s!in~.
Do you or your domestic partner claim any exemption to public record disclosure pursuant to Section 119
Florida Statutes? ^ Yes q~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 ~~R'~'`jC ~ CP'aS~Y and
~A~ C ~ A~~NIS ,Registration Number _
is hereby terminated. ~~/
Signed: ~ Signed:
Print Name: ~L1JRe~Cr/ CRc~sgY' Print Name:
Address: ~~ ~~ ~'K"'ni AyG ~ Sot
F,r~I~.NII, F'Cr ~3i~fa
Telephone Number (3(j~j y[.,~ - SS~i2~
Notarization: (Required)
Stale of ~~c' ; c! ~
County of A~~ ~c
asp
~` 1 ~ ~.
~~ ~~ ~ ~
Address: o%~~ ~ ~ ~ 1 ~ '
Telephone No. (~~/ ~~~ ~ ~ ~ y~~---
Sworn to and subscribed before me this ~-- I day of ~~ t~rl \ , , 200 ~ by ~~~~ ~TtT and
who are personally known .'`~or produced Identification
Signature of Notary Public
For Clerk's Use nly: /~ 1~
Filing Date ~1 D O~ MCR# a7 /~ Received
r ~~~Notary Qublic State of Fbflda
~~~ Oscar Petit
P My Commission DD434307
~~ ~d~ Expires 0513012009
~,z :~ wd i z ~~ Boot
~~~
F:\CLER\$ALL\DOMESTIC PARTNERSHIP\Registration Packet Forms\DRAFT- Termination2 declaration new logo.doc