HomeMy WebLinkAboutDeclaration ApplicationCity of Iowa City
Declaration of Domestic Partnership
Pursuant to Article VI of the Iowa City Human Rights Ordinance, the undersigned hereby declare the
following to be true:
1. We are in a relationship of mutual support, caring and commitment and are responsible for each other’s
welfare.
2. We are not married or in any other domestic partnership and have not been so for the last ninety (90)
days preceding the date of this declaration.
3. We are not related by blood closer than permitted under the marriage laws of the state.
4. We are at least 18 years of age and otherwise competent to enter into a contract.
5. At least one of us resides in Iowa City, or at least one of us is employed in Iowa City.
6. We intend to provide the City with written notification if there is any change attested to in this document.
To the best of our knowledge, the above statements are true and correct.
Print Name _____________________________ Print Name _____________________________
Address _____________________________ Address _____________________________
_____________________________ _____________________________
Signature _____________________________ Signature _____________________________
If both parties cannot sign at the same time, separate notarization is required for each signature.
Subscribed and sworn to before me this Subscribed and sworn to before me this
_______ day of _________________, 20______ _______ day of _________________, 20______
_______________________________________ ______________________________________
Notary Public, Johnson County, Iowa Notary Public, Johnson County, Iowa
My Commission Expires: My Commission Expires:
CERTIFIED STATEMENT:
The parties who have signed and attested to the requirements for Domestic Partnership eligibility
are considered Domestic Partners for purposes of Title 2, Article VI of the Human Rights Ordinance
of Iowa City, Iowa.
City Clerk
INFORMATION COLLECTED ON THIS DOCUMENT IS PUBLIC AND MAY BE VIEWED BY ALL
REQUESTORS.
This form must be accompanied by a $30.00 application fee. civright/declaration of dp.doc