DECLARATION OF DOMICILE TO THE CLERK OF THE COURT FOR BREVARD COUNTY, FLORIDA: This is my declaration of domicile in the State of Florida, that I am filing this day in accordance and in conformity with Section 222.17, Florida Statues. I hereby declare that I reside in and maintain a place of abode at: (Street and Number) (City) (County) (Zip Code) which place of abode I recognize and intend to maintain as my permanent home and, if I maintain another place or places of abode in some other state or states, I hereby declare that my above-described residence and abode in the State of Florida constitutes my predominant and principal home, and I intend to continue it permanently as such. I am, at the time of the making of this declaration, a bona fide resident of the State of Florida, residing at: (Street and Number) (City) (County) (Zip Code) (County) (Zip Code) I formerly resided at: (City) and the place or places where I maintain another place or places of abode are as follows: Spouse: Children: Ages: (Signature) (Print or type name) STATE OF FLORIDA COUNTY OF BREVARD The foregoing instrument was acknowledged before me this ___ day of ______________, A. D., 20 ____, by __________________________________ who is personally known to me or who has produced _____________________ as identification and who did/did not take an oath. (SEAL) Notary Public Printed Name My Commission Expires: American LegalNet, Inc. www.FormsWorkflow.com