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STATEMENT TERMINATING DOMESTIC PARTNERSHIP
STATE OF IOWA:
COUNTY OF JOHNSON: SS.:
I, the undersigned, do declare that:
1. I,___________________________________, and _________________________________ are no longer domestic
partners.
2. I sent a copy of this notice to my former domestic partner on ______________.
Mailed a copy or copies of this statement certified mail to:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
3. I provided the City with the original or copy of the certified mail returned receipt.
4. I declare under penalty of perjury under the laws of the State of Iowa that the statements
above are true and correct.
Dated: ___________________________________, 20________, in Iowa City, Iowa.
______________________________________________________ __________________________________________________________
Print Name Address
______________________________________________________
Signature
Subscribed and sworn to before me this _____________ day of _____________________________, 20__________.
_________________________________________________________
Notary Public, Johnson County, Iowa
My Commission Expires: _________________________
A domestic partnership will be considered terminated with the earlier of the following occurs:
1. One of the persons in the domestic partnership dies:
2. Ninety (90) days elapse after both partners file a notice of termination of the domestic partnership;
or
3. Ninety (90) days elapse after one partner files a notice of termination of domestic partnership and
provides proof that notice has been mailed to the other partner at their last known address, or that
the partner cannot be located or refuses to accept the mail notice. A properly mailed notice is
returned as refused or undeliverable shall be adequate proof.