PINELLAS COUNTY AFFIDAVIT OF TERMINATION
OF DOMESTIC PARTNERSHIP
Pinellas County Ordinance § 70-238 Pinellas County Code
I swear or affirm under penalty of perjury that:
1.) The Domestic Partnership, Domestic Partnership Registry #BK PG ,
between: , Former Domestic Partner
and the undersigned, is hereby terminated.
2.) I understand that this termination of the domestic partnership is effective upon filing
with the Clerk of Court, making the domestic partnership null, void and of no future
force and effect.
3.) I understand that upon the filing of this termination Domestic Partnership Registry
#BK PG , shall no longer appear in the Domestic Partnership
Registry.
4.) On , I provided a copy of this Affidavit of Termination
of
Domestic Partnership to my former domestic partner at their last known address.
Signature:
Print
Name:
Address:
Telephone
Number:
Date
of
Birth:
Notarization: (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 produced the following identification ________________________.
__________________________________________ SEAL
Notary Public or Authorized Official
__________________________________________
Name 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.
