Address Street: Apartment Number: City: Work Phone # (With area code): State: Zip Code: Work Fax # (with area code): County: 2. Domestic Partner Information Please print. Last Name: First Name: Social Security #: Gender: Male Female Middle Initial: Date of Birth (mm/dd/ccyy): Home Address Street: Apartment Number: City: State: Zip Code: County: 3. Statement of Termination I, the undersigned, declare under oath that (domestic partner name) an.
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