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EXHIBIT A <br /> <br /> Registration No. <br /> City of Eugene Fee Received: $ <br /> <br /> DomesticPartnership' Registration <br /> <br />We the undersigned declare that: <br /> 1. we live as a family, are in a relationship of'mutual support, caring and commkmenL and h~tend to <br /> remain in such a relationship: <br /> neither of us is married or registered as the domestic pa~ner of any other person in any j urisdictiom <br /> nor has either terminated a registered domestic pam~ership wkhin the preceding six months: <br /> 3. we are both at least 18 years of age: and <br /> we are not related by blood kinship closer than ~ould bar marriage in the state of Oregon, and are <br /> mentally competent to consent to contract. <br /> <br />We fu~her aRest that: <br /> 1. we understand that the registration of domestic pam~ership is evidence of a domestic pa~nership of <br /> continuous duration: and ~ <br /> 2. we agree to file a statement ofte~ination if the pa~nership is terminated {except by deatM or if <br /> any of the above declarations is no longer true. <br /> <br />We do hereby swear or affirm that the in~brmation stated above is true and correct to the best of our know ledge. <br /> <br /> First M.l. Last First M.I. Last <br /> <br /> Address Address <br /> <br /> City. State and Zip Code City, State and Zip Code <br /> <br /> Sigmmwe Signature <br /> Subscribed and sworn to (or affirmed) before me on .20 <br /> <br /> by and <br /> <br /> Notary Public lbr the State of Oregon <br /> My Commission Expires: <br /> City of Eugene Title: <br /> <br /> htlomlat~on abo~ e th~s hne ~s pubhc mibrmanon <br /> <br /> Name (Print) Name (Print) <br /> <br /> Date of Birth Date of B~rth <br /> <br /> Place of Birth-City/State/CountD; Place of Bkth-City/State/Country <br /> <br />Dl~tr~bumm Mine - confidentml filc/ pink - applicants / )clkm - Clt3 file Rex 01/2003 <br /> <br /> <br />