Revised 1/5/21
Amended Declaration of
Domestic Partnership
RETURN TO:
space above reserved for recording information
INSTRUCTIONS
Complete the following information to change the legal name of a partner already registered in a Domestic Partnership.
AFFIRMATION
I swear or affirm under penalty of perjury that:
1. I am a domestic partner registered in Palm Beach County, Florida. The registry number of my domestic
partnership is
____________________.
2. The undersigned’s legal name was changed pursuant to the entry of a court order.
3. The registration of domestic partnership should be amended to reflect my new name as follows:
Partner
Requesting Name Change:
Name of Partner as indicated on original partnership registration:
New Name of Partner as indicated on court order:
STATEMENT
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this petition and that the punishment
for making a false statement includes fines and/or imprisonment.
Signature of Party:
Date:
Printed Name:
Address:
City:
State:
Zip:
STATE OF FLORIDA
COUNTY OF PALM BEACH
Sworn to (or affirmed) and subscribed before me by means of physical presence or online notarization, this _______
day of _______________, _______ by
:
_____________________________, who personally known to me, or who has produced
___________________________________ as i
dentification.
_________________________________
Notar
y Public or Deputy Clerk of Court
__________________________________
[Pr
int, type or stamp commissioner name of notary or clerk]
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