BRING COMPLETED APPLICATION FORM WITH THE $35 REGISTRATION FEE IN CASH TO:

OFFICE OF THE CITY CLERK – CITY HALL, 44 S. MAIN, EUREKA SPRINGS, AR

OFFICE HOURS: Monday through Friday 9:30 A.M. TO 12 P.M. 1:30 TO 4:30 P.M.

Certificates of Domestic Partnership Registration cannot be mailed to applicants. You must appear in person to be registered.

DECLARATION OF DOMESTIC PARTNERSHIP

City of Eureka Springs, Arkansas

Applicant One ________________________________________________________

City ___________________________ State ________________________________

Applicant Two ________________________________________________________

City ___________________________ State _________________________________

Yes ____ We are in a relationship of mutual support, caring and commitment.

Yes ____ We are each other’s sole domestic partner and intend this relationship to continue indefinitely.

Yes ____ We are both at least 18 years of age.

Yes ____ We agree to notify the City Clerk of the City of Eureka Springs of any change in the status of our domestic partnership

WE, THE UNDERSIGNED, CONSIDER OURSELVES TO BE DOMESTIC PARTNERS AS DESCRIBED ABOVE, AND WISH TO REGISTER OUR DOMESTIC PARTNERSHIP WITH THE CITY OF EUREKA SPRINGS, ARKANSAS, OFFICE OF THE CITY CLERK, PURSUANT TO ORDINANCE 2052, AND REQUEST THAT THE CITY CLERK ISSUE TO US A CERTIFICATE OF REGISTRATION OF DOMESTIC PARTNERSHIP.

We understand that the Registration of Domestic Partnership is not a marriage certificate.

We understand that the Registration of Domestic Partnership does not afford our relationship any new or different legal status.

We understand that neither this application nor the registration is intended to create any new or different legal rights or responsibilities.

We understand that neither this application nor the registration is intended to either establish or evidence any contractual relationship or contractual obligations between us.

We understand that this Application for Domestic Partnership and a Registration of Domestic Partnership issued by the Office City Clerk in Eureka Springs, Arkansas, are public records (pursuant to Arkansas Code § 25-19-105).

APPLICANT ONE APPLICANT TWO

________________________________________________ ____________________________________________

Payment Received _________ Date Certificate Issued ________ Recorded in Book _____ Page _______