Fillable Declaration of Domestic Partnership (Clerk of the Circuit Court & Comptroller, Palm Beach County)

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Declaration of Domestic Partnership (Clerk of the Circuit Court & Comptroller, Palm Beach County)

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The Declaration of Domestic Partnership (Clerk of the Circuit Court & Comptroller, Palm Beach County) form is 2 pages long and contains:

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BROWSE CLERK OF THE CIRCUIT COURT & COMPTROLLER, PALM BEACH COUNTY FORMS

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Revised 01/05/21
Declaration of Domestic Partnership
RETURN TO:
space above reserved for recording information
INSTRUCTIONS
Complete the following information to declare a domestic partnership.
AFFIRMATION
We swear or affirm under penalty of perjury that:
1. We are residents of Palm Beach County;
2. We are both at least eighteen (18) years old and competent to contract;
3. We are not married to each other or anyone else;
4. We are the sole domestic partner of the other person;
5. We are not related to the other by blood;
6. We consent to the domestic partnership relationship without force, duress or fraud;
7. We agree to be jointly responsible for each other’s basic food, shelter, common necessities of life and welfare;
8. We have not been a member of another domestic partnership for the past year;
9. We share our primary residence with each other;
10. We consider ourselves to be a member of the immediate family of each other;
11. We share financial responsibilities as domestic partners; and that
12. The name and mailing addresses of each domestic partner are:
Partner 1: Printed Name: _______________________________________________________________________________
Address: ____________________________ City: _____________________ State: ________ Zip:____________
Partner 2: Printed Name: _______________________________________________________________________________
Addres
s: ____________________________ City: _____________________ State: ________ Zip:____________
DOCUMENTATION
The documentation as indicated below is provided with this declaration. Copies may be presented in lieu of originals.
Documentation will be returned to you. Please check those items presented.
To establish mutual residence, one (1) of the following must be presented:
___ Current mortgage, deed or lease showing both names
Current driver’s licenses showing the same address for both partners
Current tax returns showing the same address for both partners
Current government issued photo identification showing the same address for both partners
___
___
___
To establish joint financial responsibility, two (2) of the following must be presented:
___ Current mortgage, deed or lease showing both names
Current statement from joint bank account
Current credit card statement with same account number for both names
Vehicle title showing common ownership
A beneficiary designation form for a retirement plan or life insurance policy signed and completed
to the effect that one domestic partner is the beneficiary of the other
Wills designating the other as primary beneficiary
___
___
___
___
___
STATEMENT
Acknowledgement:
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this petition and that the punishment
f
or making a false statement includes fines and/or imprisonment.
Signature: 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
: ___________________________________ personally known to me, or who produced
_______________________ as
identification.
Notary Public or Deputy Clerk of Court
__________________________________
[Print, type or stamp commissioner name of notary or clerk]
Deputy Clerk Signature and Seal
Acknowledgement:
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:
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
: ___________________________________ personally known to me, or who produced
_______________________ as
identification.
Notary Public or Deputy Clerk of Court
__________________________________
[Print, type or stamp commissioner name of notary or clerk]
Deputy Clerk Signature and Seal
Revised 01/05/21
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Declaration of Domestic Partnership (Clerk of the Circuit Court & Comptroller, Palm Beach County)

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Completed 5 July 2021

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