Fillable Domestic Partnership Registration Form REVISED 2019 (City of Oakland)

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Domestic Partnership Registration Form REVISED 2019 (City of Oakland)

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The Domestic Partnership Registration Form REVISED 2019 (City of Oakland) form is 3 pages long and contains:

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

OfficeoftheCityClerk OneFrankH.OgawaPlaza,2

nd

Floor,Room201,Oakland,CA 94612 Phone(510)238‐3226

INSTRUCTIONSFORFILINGTHEAFFIDAVITOFDOMESTICPARTNER S HIP



TheAffidavitofDomesticPartnershipFormmaybeusedtoestablishadomest i cpartnership



betweentwo

personsmeetingtherequirement sasstatedonthefrontoftheform. ACer tificateof



Registrationof

DomesticPartnershipwillbeissuedtothepartnersaftertheaffidavitisfiled.



CompletetheAffidavitofDomesticPartnershipFormasfo llows :





EachpersonmustsigntheirrespectivesignaturesinthepresenceoftheCityClerkRepresentativeor

NotaryPublic.ThenotarizationshouldbepresentedtoClerkstaff.





Eachpersonmustprinttheirnameslegibly. Thenamesmustbeprintedinthe



orderrequested:

Lastname,Firstname,Middlename





Acompleteaddressisrequired(address,city,state,zipcode). Print



legibly. Donotabbreviatethecity

name.



DOCUMENTS: Eachpartnermustshowproofofidentitybypresentingavalidgovernment‐issuedpicture

identificationcard.Also,youmustprovideamajorutilitybill(i.e.PG&E,EastBayMUD)ineitherperson's

nameandbankstatement(ordifferentutility)intheotherperson'sname.Alldocuments,includingIDs,must

havethesameaddresstowhichbothpartiesareregistering.PLEASENOTE:YoumustliveinOaklandorwork

FORtheCityofOaklandtofileforDomesticPartnership.IfyouworkfortheCityofOaklandanddonotlivein

Oakland,youwillneedtoprovideproofofemployment(paystuborCityofOaklandIDcard).



TWOWAYSTOOBTAINCERTIFICATE:



 Toregisterinperson(byappointmentonly,call(510)238‐3226toscheduleorschedulean

appointmentonlineathttps://www.schedulicity.com/scheduling/OOT4RY),bothpartnersmust

appearinpersontotheOfficeoftheCityClerklocat ed



at: OneFrankH.Ogawa,2



Floor,Room201,

Oakland,CA 94612.



OR



 Toregisterbymail,bothpartnersmustappear beforeaNotaryPublictosigntheAffidavitof

Domestic



Partnership.The Affidavitisthenforwarded,withtherequiredfeeanddocumentsto:



TheOfficeoftheCityClerk

ATTN:DomesticPartnershipRegistration



OneFrankH.Ogawa



Floor,Room201



Oakland,CA 94612



FEES: Thenon‐refundablefeefo rfilingAffidavitofDomesticPartnershipis$40.00. Acceptableme thodsof

paymentarecash,check,cashiercheckormoneyorder.Checks,cashierchecksandmoneyordersshould

bemadepayableto:CityofOakland.



Failuretoprovidetherequireddocumentationmayresultinthereschedulingofyourappointmentorreturn

ofyourdocumentsbymail.



OfficeoftheCityClerk OneFrankH.OgawaPlaza,2

nd

Floor,Room201,Oakland,CA 94612 Phone(510)238‐3226

Certificate

Number:

CITY HALL



ONE FRANK H. OGAWA PLAZA



OAKLAND,CALIFORNIA 94612



(510)238‐3226

OfficeoftheCityClerk





CityClerkandClerkoftheCouncil



AFFIDAVITOFDOMESTICPARTNERSHIP

We,theUndersigned,dodeclarethat:

 Weareboth over 18 years ofageand have chosen toshare one another'slives inanintimateandcommitted

relationshipofmutualcaring;

 Welivetogether;

 Wearejointlyresponsibleforbasi clivingexpenseswhichweincurduringthedomestic

partnership;

 OneofusisanemployeeoftheCityofOakland,orbothofusresidetogetherwithinthecitylimits;

 Neitherofusismarried,norarewerelatedtoeachotherin awaywhichwouldbarmarriageinCalifornia; 

 Neitherofushas

hadadifferentdomesticpartnerlessthansixmonthspriortosigningthisAffidavit;

 WeagreetonotifytheCityofanychangesinthestatusofourdomesticpartnershipagreement.

WedeclareunderpenaltyofperjuryandunderthelawsoftheStateofCali forniathatthestatements

hereinaretrue

andcorrecttothebestofourknowledgeandbelief.

PARTNER1PARTNER2

________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________



_____________________________________________ _____________________________________________

(Print)Last First Middle  (Print)Last First Middle



_____________________________________________ _____________________________________________

SignatureofPartnerasStatedAboveSignatureofPartnerasStatedAbove

    

AddressCityStateZipCode



_____________________________________________ _____________________________________________

PhoneNumberPhoneNumber



OfficeoftheCityClerkOneFrankH.OgawaPlaz a,2

nd

Floor,Room201,Oakland,CA 94612 Phone510‐238‐3226



___________________________________



IfmailingthisaffidavittotheClerk's



Witness Si

nature&Date

(

thissection

orC

C

esentati

eONLY

)

Office



leasehavenotarized

(

see below

)

AffidavitofDomesticPartnership Notarization

StateofCalifornia,Countyof 



On ,beforeme, NotaryPublic,personallyappeared



 





personally known tome(or proved tomeonthebasis ofsatisfactory evidence) tobetheperson(s) whosename(s)

is/aresubscribed tothe within instrument andacknowledged tomethat he/she/they executedthesamein

his/her/their authorized capacity(ies), and that byhis/her/their

signature(s) ontheinstrument theperson(s), orthe

entity upon

behalf ofwhich theperson(s) acted, executed theinstrument.

WITNESSmyhandandofficialseal

.

[PLACENOTARYPUBLICSEALHERE]





   

SignatureofNotaryPublicDate



OfficeoftheCityClerk OneFrankH.OgawaPlaz a,2

nd

Floor,Room201,Oakland,CA 94612 Phone(510)238‐3226

OptionalQuestionnaireforDomesticPartnership



APPLICANTS:WereceivemanyinquiriesregardingtheCity’sDomesticPartnershipRegistrationProgramfrom

otheragenciesandthepublic.Inanefforttobetterrespondtooftenaskedquestions,wehaveincludedthis

optionalquestionnairethatwillbeseparatedfromyournameandusedforstatisticaldataonly.



DescriptionofEthnicCategories:



 AfricanAmerican:NotofHispanicorigin.

 White:NotofHispanicorigin.

 Hispanic:AllpersonsofMexican,PuertoRican,Cuban,CentralorSouthAmerican,orotherSpanish

cultureororigin,regardlessofrace.

 Asian/PacificIslander:Allpersonshavingoriginsinanyoftheoriginalpeoples

ofthefarEast,

SoutheastAsia,theIndianSubcontine nt, orthePacificIslands.Thisareaincludes,forexample:China,

Japan,Korea,andSamoa.

 NativeAmerican/AlaskanNative:AllpersonshavingoriginsinanyoftheoriginalpeoplesofNorth

America,andwhomaintainculturalidentificationthroughtribalaffiliationorcommunity

recognition.

Pleaseidentifywhichtribewithwhichyouareaffiliated.



Partner1 ☐Male☐Female



Partner2 ☐Male☐Female



Pleasecheckoneonlyfortheracial/ethniccategory

youmostcloselyidentifywith:

☐AfricanAmerican

☐White

☐Hispanic 

☐Asian/PacificIslander

☐NativeAmerican/AlaskanNative

☐Other



Pleasecheckoneonlyfortheracial/ethniccategory

youmostcloselyidentifywith:

☐AfricanAmerican

☐White

☐Hispanic 

☐

Asian/PacificIslander

☐NativeAmerican/AlaskanNative

☐Other



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Domestic Partnership Registration Form REVISED 2019 (City of Oakland)

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Completed 23 July 2020

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