DOMESTIC PARTNERSHIP REGISTRATION

TERMINATION

City of Eureka Springs, Arkansas

Applicant One ________________________________________________________

City ___________________________ State ________________________________

Applicant Two ________________________________________________________

City ___________________________ State _________________________________

I/we request that the Domestic Partnership Registration of:

________________________________ and _________________________________

(Registrant #1) (Registrant #2)

be terminated as of (date) ________________________________________________.

Signature of at least one registrant is required.

A Domestic Partnership created pursuant to Ordinance 2052 shall terminate upon the first to occur of:

_____ 1. The death of one of the domestic partners; or

_____ 2. The marriage of one of the domestic partners; or

_____ 3. The execution of a Certificate of Termination by one of the domestic partners.

A Certificate of Termination shall be in such form as may be prescribed by the City Council but shall contain:

1. The name of each domestic partner;

2. A statement that one or more of the criteria used to grant the domestic partnership is no longer valid; and

3. The signatures of both domestic partners, or in lieu thereof, a statement by the petitioning partner that a copy of the Termination Certificate has been sent to the other domestic partner's last known address.

A Certificate of Termination may be filed with the City Clerk at City Hall, 44 S. Main, Eureka Springs, AR 72632, by mail or in person. The fee to be paid to the City of Eureka Springs for registration of a Termination of Domestic Partnership shall be Twenty ($20.00) Dollars, to be paid in cash.

Fee Received _______ Date Received _____________________ By ______________________________

Date Termination Filed_______________________________ Book ______ Page ________

Date Registration Filed _______________________________ Book ______ Page ________

_____________________________________________

Mayor or City Clerk of Eureka Springs, Ark.