Fillable PINELLAS COUNTY AFFIDAVIT OF DOMESTIC PARTNERSHIP REGISTRATION FORM (Pinellas County Clerk of the Circuit Court and Comptroller)

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PINELLAS COUNTY AFFIDAVIT OF DOMESTIC PARTNERSHIP REGISTRATION FORM (Pinellas County Clerk of the Circuit Court and Comptroller)

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PINELLAS COUNTY AFFIDAVIT OF DOMESTIC
PARTNERSHIP
REGISTRATION
FORM
§ 70-237 of the Pinellas County
Code
Instructions:
Both partners and two (2) witnesses must complete and submit this form (notarization is required) to
the Clerk of the Court (with proof of identification) at one of the three following locations:
• Clearwater Courthouse – 315 Court St., Room 150, Clearwater, FL 33756
• North County Branch Office – 29582 U.S. 19 N., Room 101, Clearwater, FL 33761
• St Petersburg Branch Office – 545 First Ave. N., Room 153, St Petersburg, FL 33701
A filing fee of $50.00 is required and must be remitted to the Clerk of Court at the time of application.
We, the undersigned co-applicants, do declare that we meet the requirements of Section 70-237(d) of
the Pinellas County Code and agree to the following statements:
Initials of partners
*I am at least eighteen (18) year of age and competent to contract.
*I am not married under the laws of the State of Florida, nor am I a partner in a domestic
partnership or a member of a civil union and anyone other hand the co-applicant.
*I am not related to my co-applicant by blood as defined in Florida Law.
*I consider myself to be a member of the immediate family of the co-applicant and I am jointly
responsible for maintenance and support of the domestic partnership.
*I acknowledge that I reside in mutual residence with my co-applicant.
*I designated the co-applicant to act as my healthcare surrogate as provided in Chapter 765,
Florida Statutes and my agent to direct the disposition of my body after death.
*I agree to be responsible for the basic food and shelter of my co-applicant.
*In the event that I have been determined incapacitated, I designate the co-applicant as my
preneed guardian as defined in Chapter 744, Florida Statutes.
*I agree to immediately notify the Clerk of Court’s Office, in writing, if the terms of the
Registered Domestic Partnership are no longer applicable or if one of the domestic partners to
terminate the domestic partnership.
Mailing Address for Domestic Partners City State Zip
WE UNDERSTAND THAT THIS AFFIDAVIT FORM AND OUR DOMESTIC PARTNERSHIP
REGISTRATION INFORMATION IS A PUBLIC RECORD UNDER FLORIDA LAW. WE UNDERSTAND
THAT THE CLERK OF COURT IS RESPONSIBLE ONLY FOR MAINTAINING THE DOMESTIC
PARTNERSHIP REGISTRY. WE UNDERSTAND THAT THIS FORM DOES NOT CONSTITUTE A
“LIVING WILL” AS THAT TERM IS DEFINED IN SECTION 765.101, FLORIDA STATUTES. WE
ACKNOWLEDGE THAT THIS DOMESTIC PARTNERSHIP REGISTRATION IS VALID IN PINELLAS
COUNTY, FLORIDA, AND MAY NOT BE ACCEPTED IN OTHER JURISDICTIONS. WE
ACKNOWLEDGE, THEREFORE, THAT THIS DOMESTIC PARTNERSHIP REGISTRY MAY NOT
CONSTITUTE A HEALTHCARE SURROGATE OR PRE-NEED GUARDIANSHIP OUTSIDE
PINELLAS COUNTY. WE ACKNOWLEDGE THAT THIS DOMESTIC PARTNERSHIP REGISTRY
DOES NOT SUBSTITUTE FOR A POWER OF ATTORNEY. WE ACKNOWLEDGE THAT IT IS OUR
DUTY TO KEEP DOMESTIC PARTNERSHIP DOCUMENTATION ON OUR PERSON AT ALL
TIMES AND PROVIDE THE CLERK OF COURT WITH UP-TO DATE INFORMATION CONCERNING
THE STATUS OF OUR DOMESTIC PARTNERSHIP.
List the name(s) of any dependent(s) that reside(s) within the mutual household of the co-applicants
who is (are): 1) a biological, adopted, or foster child of a domestic partner; or 2) a dependent as
defined under IRS regulations; or 3) a ward of a domestic partner as determined in a guardianship or
other legal proceeding; or
4) a
person supported in whole or in part by their registered partner’s
earnings and relies on such support.
List Dependents: __________________________________________________________________
If the above is left blank, it would be automatically assumed that there are no dependents.
We swear or affirm under penalty of perjury that the statements and information provided on this form
are true and correct.
Signed on ___________________ in _________________________, ______________________
Date City State
__________________________________ _____________________________________
Signature of Applicant Witness (may not be blood relative of applicant)
Pr
int Name: ___________________________ Print Name: ___________________________
Date of Birth: _________________
__________________________________ _____________________________________
Signature of Applicant Witness (may not be blood relative of applicant)
Pr
int Name: ___________________________ Print Name: ___________________________
Date of Birth: _________________
Notarization of both signatures: (Required)
State of ________________________
County of ______________________
Sworn to and subscribed before me by means of ☐ Physical Presence or ☐ Online Notarization
on this ______ day of ________________, 20____ by ____________________ &__________________.
Who are personally known or produc
ed the following identification ______________________.
______________________________________________
Notary Public or Authorized Official
__________________________________
Nam
e printed/typed
NOTE: If either of the co-applicants claims any exemption to public record disclosure pursuant to Section 119, Florida Statutes,
the person claiming such exemption must make a separate written request for maintenance of the exemption as to this record. A form is
available upon request from the Clerk of Court for this purpose.
Revised 12/28/2020
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PINELLAS COUNTY AFFIDAVIT OF DOMESTIC PARTNERSHIP REGISTRATION FORM (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 9 February 2021

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