OfficeoftheCityClerk OneFrankH.OgawaPlaza,2
nd
Floor,Room201,Oakland,CA 94612 Phone(510)238‐3226
Certificate
Number:
CITY HALL
ONE FRANK H. OGAWA PLAZA
OAKLAND,CALIFORNIA 94612
(510)238‐3226
OfficeoftheCityClerk
F AX(510)238‐6868
CityClerkandClerkoftheCouncil TDD:(510)839‐6451
AFFIDAVITOFDOMESTICPARTNERSHIP
We,theUndersigned,dodeclarethat:
9 Weareboth over 18 years ofageand have chosen toshare one another'slives inanintimateandcommitted
relationshipofmutualcaring;
9 Welivetogether;
9 Wearejointlyresponsibleforbasi clivingexpenseswhichweincurduringthedomestic
partnership;
9 OneofusisanemployeeoftheCityofOakland,orbothofusresidetogetherwithinthecitylimits;
9 Neitherofusismarried,norarewerelatedtoeachotherin awaywhichwouldbarmarriageinCalifornia;
9 Neitherofushas
hadadifferentdomesticpartnerlessthansixmonthspriortosigningthisAffidavit;
9 WeagreetonotifytheCityofanychangesinthestatusofourdomesticpartnershipagreement.
Wedeclareunderpenaltyofperjury,andunderthelawsoftheStateofCaliforniathatthestatements
hereinaretrue
andcorrecttothebestofourknowledgeandbelief.
PARTNER1PARTNER2
________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________
_____________________________________________ _____________________________________________
(Print)Last First Middle (Print)Last First Middle
_____________________________________________ _____________________________________________
SignatureofPartnerasStatedAboveSignatureofPartnerasStatedAbove
AddressCityStateZipCode
_____________________________________________ _____________________________________________
PhoneNumberPhoneNumber
OfficeoftheCityClerkOneFrankH.OgawaPlaz a,2
nd
Floor,Room201,Oakland,CA 94612 Phone510‐238‐3226
___________________________________
IfmailingthisaffidavittotheClerk's
Witness Si
nature&Date
thissection
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Re
esentati
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leasehavenotarized
see below
.
AffidavitofDomesticPartnership Notarization
StateofCalifornia,Countyof
On ,beforeme, NotaryPublic,personallyappeared
personally known tome(or proved tomeonthebasis ofsatisfactory evidence) tobetheperson(s) whosename(s)
is/aresubscribed tothe within instrument andacknowledged tomethat he/she/they executedthesamein
his/her/their authorized capacity(ies), and that byhis/her/their
signature(s) ontheinstrument theperson(s), orthe
entity upon
behalf ofwhich theperson(s) acted, executed theinstrument.
WITNESSmyhandandofficialseal.
[PLACENOTARYPUBLICSEALHERE]
SignatureofNotaryPublicDate