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Declaration of State Registered
Domestic Partnership
See attached detailed instructions□ Filing Fee $50.00□ Filing Fee with Expedited Service $100.00

Registration Number:

DOMESTIC PARTNERSHIP DECLARATION
Chapter 26.60 RCW
PARTNER 1Name:FirstMiddle

Last

State

Country

Place of Birth:City
Date of Birth:□ MaleGender:□ Female

PARTNER 2Name:First

Middle

Last

State

Country

Place of Birth:City
Date of Birth:□ MaleGender:□ Female

ADDRESS
Mailing or Postal Address (optional):_______________________________________________________________
City __________________________________StateZip Code ____________

Street Address: ____________________________________________________
City __________________________________State

Domestic Partnership - Declaration

Zip Code ____________

Washington Secretary of State

Revised 07/14

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Declaration of State Registered Domestic Partnership
Important information:Registration of a domestic partnership may affect property and inheritance rights and is not a substitute for awill, deed, or partnership agreement. Any rights conferred by this registration may be superseded by a will,deed, or other instrument signed by either party to this domestic partnership registration.
Records of State Registered Domestic Partnerships are public and will be disclosed on request. Information
about State Registered Domestic Partnerships will be shared with the Washington State Department of Health.

Partner 1 Name (Print)

Partner 2 Name (Print)

We declare that we meet the requirements for registration of a domestic partnership pursuant to Chapter
26.60 RCW, and that:• We share a common residence;• We are both at least eighteen (18) years of age;
• Neither partner is married to anyone else, or in a state registered domestic partnership with any otherperson;• We are both capable of consenting to this domestic partnership;• We are not of any relation to each other nearer than second cousin and neither partner is a sibling,child, grandchild, aunt, uncle, niece or nephew to the other;• One of us is at least 62 years of age
These representations are true and correct, and contain no material omissions of fact to the best of ourknowledge and belief.
XPartner 1 (Signature)

XPartner 2 (Signature)

State of Washington
County ofState of Washington
County of

Signed and affirmed before me on

Signed and affirmed before me on

By Partner 1 (print name)By Partner 2 (print name)

Notary Public Signature

Notary Public Signature

My Commission Expires:

My Commission Expires:

Notary seal

Notary seal

Domestic Partnership - Declaration

Washington Secretary of State

Revised 07/14INSTRUCTIONS - Declaration of State Registered Domestic Partnership
Complete all sections. USE DARK INK ONLY
Partner 1
Complete the name, place of birth, and date of birth portion of the Declaration of State Registered DomesticPartnership.
Partner 2
Complete the name, place of birth, and date of birth portion of the Declaration of State Registered DomesticPartnership.
Address
Complete the street address portion of the form. You may also provide an additional mailing or postal address
if different than your street address.
Declaration
Both partners must sign this section. A notary is required for each partner’s signature. The form provides
space for a separate notarization allowing partners to sign at different times or places.
Additional Information
At the time of filing, the Corporations Division will provide each partner with one original Certificate of State
Registered Domestic Partnership and one wallet card showing registration of the State registered DomesticPartnership. After the date of filing, additional certificates are available from the Corporations Division for a feeof $5.00 each. Replacement wallet cards are available for a fee of $10.00 each.
Fees: The filing fee for Declaration of State Registered Domestic Partnership is $50.00. Make the checks ormoney orders payable to “Secretary of State.” If expedited service is requested then include an additional$50.00 and write “EXPEDITE” on the outside of the envelope.
All payments must be received in US Dollars. All fees are non-refundable.
Mail completed forms and payment to:
Secretary of State
Corporation Division
801 Capitol Way S
PO Box 40234
Olympia WA 98504-0234
If you have questions, need assistance, or would like to provide feedback please visit the Corporations Divisionwebsite at www.sos.wa.gov/corps or call 360-725-0377.

Domestic Partnership - Declaration

Washington Secretary of State

Revised 07/14