Revised 1/5/21
Declaration of Termination
of Domestic Partnership
RETURN TO:
space above reserved for recording information
INSTRUCTIONS
Complete the following information to declare the termination of a domestic partnership.
AFFIRMATION
I swear or affirm under penalty of perjury that:
1. I am a partner in a registered domestic partnership established in Palm Beach County, Florida.
My registration number is
___________________.
2. The Domestic Partnership has been dissolved.
3. I have notified my domestic partner of the termination of this Domestic Partnership as indicated by either:
a.
_____ My
partner has joined in this Declaration of Termination by signing below in the presence of a notary
or a deputy clerk; OR
b. _____ Notice was delivered to my former Partner by registered or certified mail, return receipt requested at
his/her last known address. I have provided the proof of service (return receipt) to the Clerk of the Circuit
Court & Comptroller’s office as required.
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.
Partner Filing Declaration of Termination of Domestic Partnership:
Printed Name:
Address: City: State:
Zip:
Signature: Date:
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
identification.
_________________________________
Not
ary Public or Deputy Clerk of the Circuit Court
___________________________
_______
[P
rint, type or stamp commissioner name of notary or clerk]
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
