#381 Glenn Chad Welch & Felix Vega (2)MIAMI EA i
City Clerk's Office - 1700 Convention Center Drive, Miami Beach, FL 33139
Phone: 305-673-7411 Email: CityClerk(a7miamibeachfl.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. 3 I
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 partnerclaim any exemption to public record disclosure pursuant to Section 119
Florida Statutes? 0 Yes D/A°. 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
F.QA x o
Former omestic Partner
Registration Number , and the undersigned, is hereby terminated, and
2. On , the City Clerk's Office was provided with his/her last known
911 6(49. t,11 20 ,4/4114,,td l t 3260/
address, which is . A copy of
the termination statement shall be served by certified or registered mail on the other Registered
Domestic Partn
Signature
Print Name (`E'. Vil/1 C (ACA (A) eICA
Address: 67)0 W;an ctiteD✓'. q i.- 14'1-4114 ; 194 t 3 J t q
Telephone Number (� ) 051— [9'1(
Notarization: (Required)
State of
County of
rata n4 w • �.L 1
Sworn to and ill cri • ed before me this day of � ` ► ' n , , a f" ' Ck4 V "�, and
who are personally known ;fir pr?oOM,cgCWIAt,gtt'f ctinats79
41 11•�.,r���Y�, Y?;yar ,,,� EXPIRES June 27, 2020
i,l, r r (407) 368.0153 FIorld•NotarySeNiop.Coi
Si‘nature of Not Public
For Clerk's Use Only:
Filing Date MCR# Received by:
F:\CLER\$ALL\DOMESTIC PARTNERSHIP\FORMS\Termination1 declaration.doc