I, , hereby declare that I reside in and maintain aplace of abode at:Street & NumberCity, State & ZIPCodewhich place of abode I recognize and intend to maintain as my permanent home and, if I maintainanother place or places of abode in some other state, I hereby declare that my above referencedresidence and abode in the State of Arkansas constitutes my predominant and principal home, andintend to continue it permanently as such.Printed NameSignatureDateNotarizationState of ArkansasCounty of Subscribed and sworn before me, a Notary Public, on this day of , . Signature of Notary PublicMy commission expires:Circuit Clerk filingSworn and subscribed to before me, , Circuit Clerk in and for theCounty of , State of Arkansas, on this day of , .(Signature of Circuit Clerk)Declaration of DomicileFor Purposes of Notary Public Application This Declaration must be: (1) Notarized 321 (2) Filed for record with the Circuit Clerk in thecounty where you reside 321 (3) Attached to your notary public application. Rev. (If you are a United States citizen, do notcomplete this form.) 001027021n024030n030007r013027r031n027035025016007031n031r$'#$t 003n026020031025022037004020031031022r006025013021 American LegalNet, Inc. www.FormsWorkFlow.com