dprAmendment
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.
AMENDMENT TO DECLARATION 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.
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.
Adding or Deleting Dependents
List the name(s) of dependent(s) who reside(s) within the household of the Registered Domestic Partnership and is (are):
1. a biological adopted, or foster child of a Registered Domestic Partner; or
2. a dependent as defined under IRS regulations; or
3. a ward of a Registered Domestic Partner as determined in a guardianship or other legal proceeding.
Add Delete ________________________________ Add Delete _______________________________
Add Delete ________________________________ Add Delete _______________________________
Change of Address
Common Residence Address City State Zip Code
Mailing Address City State Zip Code
Telephone Number
Email (Optional)
We swear or affirm under Penalty of perjury that the statements above are true and correct.
Signed on _________________________________________ in _____________________________, __________
(Date) (City) (State)
____________________________________ _______________________________________
Signature (Print legibly) Last First Middle
____________________________________ _______________________________________
Signature (Print legibly) Last First Middle
Notarization of both signatures: (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: __________________ Registration Number_________________
F:\CLER\$ALL\DOMESTIC PARTNERSHIP\FORMS\Amendment to declaration.doc