AFFIDAVIT TO OBTAIN CERTIFIED

COPIES OF DOMESTIC PARTNERSHIP CERTIFICATES

Fee: $10.00 per copy

NAME OF PARTNER A: ____________________________________________________________

EXACT NAME OF PARTNER A AS RECORDED ON THE DOMESTIC PARTNERSHIP RECORD

NAME OF PARTNER B: __________________________________________________________

EXACT NAME OF PARTNER B AS RECORDED ON THE DOMESTIC PARTNERSHIP RECORD

PLACE WHERE DOMESTIC PARTNERSHIP RECORDED (MUNICIPALITY)

EXACT PLACE WHERE THE DOMESTIC PARTNERSHIP WAS FILED (CITY)

DATE OF DOMESTIC PARTNERSHIP CERTIFICATION______________________________________

EXACT DATE OF THE CERTIFICATION (MONTH, DAY, YEAR)

NUMBER OF COPIES: _________

PURPOSE FOR WHICH CERTIFICATE IS NEEDED: __________PROOF OF CERTIFICATION

(Initial)

OTHER: _________________________________________________________________________

YOUR NAME: ___________________________________________________

PLEASE PRINT

YOUR ADDRESS: ______________________________________________________

______________________________________________________

CITY STATE ZIP CODE

YOUR TELEPONE NUMBER: (________)_________________

AREA CODE

YOUR RELATIONSHIP TO ABOVE NAMED: ____________________________________

YOUR SIGNATURE:_________________________________________________________

DATE

FOR OFFICE USE ONLY:

IDENTIFICATION PROVIDED __________________________________________________

(1 REQUIRED IF PHOTO

2 REQUIRED IF NO PHOTO) __________________________________________________

RECEIPT NUMBER: ___________________CHECK OR CASH: ___________________

CERTIFICATE NUMBER(S) ________________________________________FORM NO.____________

PERSON PREPARING CERTIFIED COPY: _________________________________________