TerminationOnepartnerSigns
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 PARTNERSHIP
Article IV -Chapter 62-161 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 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 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 ___________________________________________
Former Domestic Partner
Registration Number ___________, and the undersigned, is hereby terminated, and
2. On _____________________, the City Clerk’s Office was provided with his/her last known
address, which is ______________________________________________________. A copy of
the termination statement shall be served by certified or registered mail on the other Registered
Domestic Partner.
Signature ____________________________________ _____________________________
Print Name ____________________________________
Address: ____________________________________
Telephone Number ( ) _________________________
Notarization: (Required)
State of ___________________
County of __________________
Sworn to and subscribed before me this _____ day of _________________, 200__ by __________________________ and
__________________________ who are personally known ____ or produced Identification _________________________.
___________________________________________
Signature of Notary Public
For Clerk’s Use Only:
Filing Date ___________ MCR#____________________________ Received by: __________________
F:\CLER\$ALL\DOMESTIC PARTNERSHIP\FORMS\Termination1 declaration.doc