PINELLAS COUNTY
AMENDMENT OF DOMESTIC PARTNERSHIP
Pinellas County Ordinance § 70-237(e) Pinellas County Code
The partners to the below registered Domestic Partnership swear or affirm under penalty of
perjury that:
Domestic Partnership Registry Number #BK PG , between:
, and , is hereby
amended in order to reflect a change in:
1. The legal address of the Register Domestic Partners as follows:
(New address);
or
2. The legal name of a domestic partner has changed as follows:
(Name change); or
3. The list of dependents has changed as follows:
(List all current dependents of the Domestic Partnership).
Signature of Domestic Partner
Print Name:
Date
of
Birth:
Signature of Domestic Partner
Print Name:
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
A filing fee of $25.00 is required and must be remitted to the Clerk of Court at the time of filing this
Amendment.
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.
