OfficeoftheCityClerk OneFrankH.OgawaPlaza,2
nd
Floor,Room201,Oakland,CA 94612 Phone(510)2383226
INSTRUCTIONSFORFILINGTHEAFFIDAVITOFDOMESTICPARTNER S HIP
TheAffidavitofDomesticPartnershipFormmaybeusedtoestablishadomest i cpartnership
betweentwo
personsmeetingtherequirement sasstatedonthefrontoftheform. ACer tificateof
Registrationof
DomesticPartnershipwillbeissuedtothepartnersaftertheaffidavitisfiled.
CompletetheAffidavitofDomesticPartnershipFormasfo llows :
EachpersonmustsigntheirrespectivesignaturesinthepresenceoftheCityClerkRepresentativeor
NotaryPublic.ThenotarizationshouldbepresentedtoClerkstaff.
Eachpersonmustprinttheirnameslegibly. Thenamesmustbeprintedinthe
orderrequested:
Lastname,Firstname,Middlename
Acompleteaddressisrequired(address,city,state,zipcode). Print
legibly. Donotabbreviatecity
name.
DOCUMENTS: Eachpartnermustshowproofofidentitybypresentingavalidgovernmentissuedpicture
identificationcard.Also,youmustprovideamajorutilitybill(i.e.PG&E,EastBayMUD)ineitherperson's
nameandbankstatement(ordifferentutility)intheotherperson'sname.Alldocumentsmusthavethesame
addresstowhichbothpartiesareregistering.PLEASENOTE:YoumustliveinOakland(orworkFORtheCityof
Oakland)tofileforDomesticPartnership.
TWOWAYSTOOBTAINCERTIFICATE:
Toregisterinperson(byappointmentonly,call(510)2383226toscheduleorschedulean
appointmentonlineathttps://www.schedulicity.com/scheduling/OOT4RY),bothpartnersmust
appearinpersontotheOfficeoftheCityClerklocat ed
at: OneFrankH.Ogawa,2
nd
Floor,Room201,
Oakland,CA 94612.
OR
Toregisterbymail,bothpartnersmustappear beforeaNotaryPublictosigntheAffidavitof
Domestic
Partnership.The Affidavitisthenforwarded,withtherequiredfeeanddocumentsto:
TheOfficeoftheCityClerk
ATTN:DomesticPartnershipRegistration
OneFrankH.Ogawa
2
nd
Floor,Room201

Oakland,CA 94612
FEES: Thenonrefundablefeefo rfilingAffidavitofDomesticPartnershipis$40.00. Acceptableme thodsof
paymentarecash,check,cashiercheckormoneyorder.Checks,cashierchecksandmoneyordersshould
bemadepayableto:CityofOakland.
Failuretoprovidetherequireddocumentationmayresultinthereschedulingofyourappointmentormail
returnofyourdocuments.
OfficeoftheCityClerk OneFrankH.OgawaPlaza,2
nd
Floor,Room201,Oakland,CA 94612 Phone(510)2383226
Certificate
Number:
CITY HALL
ONE FRANK H. OGAWA PLAZA
OAKLAND,CALIFORNIA 94612
(510)2383226
OfficeoftheCityClerk
F AX(510)2386868
CityClerkandClerkoftheCouncil TDD:(510)8396451
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.
PARTNER1PARTNER2
________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________
_____________________________________________ _____________________________________________
(Print)Last First Middle (Print)Last First Middle
_____________________________________________ _____________________________________________
SignatureofPartnerasStatedAboveSignatureofPartnerasStatedAbove
AddressCityStateZipCode
_____________________________________________ _____________________________________________
PhoneNumberPhoneNumber
OfficeoftheCityClerkOneFrankH.OgawaPlaz a,2
nd
Floor,Room201,Oakland,CA 94612 Phone5102383226
___________________________________

IfmailingthisaffidavittotheClerk's
Witness Si
g
nature&Date
(
thissection
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orC
i
t
y
C
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r
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Re
pr
esentati
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)
Office
,
p
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]


SignatureofNotaryPublicDate
OfficeoftheCityClerk OneFrankH.OgawaPlaz a,2
nd
Floor,Room201,Oakland,CA 94612 Phone(510)2383226
OptionalQuestionnaireforDomesticPartnership
APPLICANTS:WereceivemanyinquiriesregardingtheCity’sDomesticPartnershipRegistrationProgramfrom
otheragenciesandthepublic.Inanefforttobetterrespondtooftenaskedquestions,wehaveincludedthis
optionalquestionnairethatwillbeseparatedfromyournameandusedforstatisticaldataonly.
DescriptionofEthnicCategories:
AfricanAmerican:NotofHispanicorigin.
White:NotofHispanicorigin.
Hispanic:AllpersonsofMexican,PuertoRican,Cuban,CentralorSouthAmerican,orotherSpanish
cultureororigin,regardlessofrace.
Asian/PacificIslander:Allpersonshavingoriginsinanyoftheoriginalpeoples
ofthefarEast,
SoutheastAsia,theIndianSubcontine nt, orthePacificIslands.Thisareaincludes,forexample:China,
Japan,Korea,andSamoa.
NativeAmerican/AlaskanNative:AllpersonshavingoriginsinanyoftheoriginalpeoplesofNorth
America,andwhomaintainculturalidentificationthroughtribalaffiliationorcommunity
recognition.
Pleaseidentifywhichtribewithwhichyouareaffiliated.
Partner1 MaleFemale
Partner2 MaleFemale
Pleasecheckoneonlyfortheracial/ethniccategory
youmostcloselyidentifywith:
AfricanAmerican
White
Hispanic
Asian/PacificIslander
NativeAmerican/AlaskanNative
Other
Pleasecheckoneonlyfortheracial/ethniccategory
youmostcloselyidentifywith:
AfricanAmerican
White
Hispanic
Asian/PacificIslander
NativeAmerican/AlaskanNative
Other