DECLARATION OF DOMICILE TO THE STATE OF FLORIDA AND COUNTY OF CLAY: 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 _________________________________________________________ was formerly a legal resident of (please print name) ________________________________________________________________and (city and state) I resided at ____________________________________ however, (street address) I have changed my domicile to and am and have been a bona fide resident of the State of Florida since the ________ day of __________,20 ______ . I now reside at __________________________________________ County, Florida and this statement is to be taken as my declaration of actual legal residence and permanent domicile in this State and County to the exclusion of all others, and I will comply with all requirements of legal residents of Florida. I understand that as a legal resident of Florida: I am subject to intangible taxes; I must purchase Florida license plates for motor vehicles, if any, owned by me and/or my spouse; I must vote in the precinct of my legal domicile (if I vote), and that my estate will be probated in the Florida Courts. I was born in the USA: Yes_________ No______ Place of birth: Naturalized citizen ______ Where: __________________________ Date:_________ No.: _______________ Permanent Visa: Yes ________No _____ Date ___________ No.: __________________________________ State of Florida County of CLAY Signature as printed above Sworn to (or affirmed) and subscribed before me this ______ day of _________ ,20 by _____________________________________ ____ Personally known OR ____ Produced identification (type of identification) Clay (street address) Mailing address ____________________________________ City / State / Zip (Signature of Notary/Deputy Clerk) (Type or print name) Penalty for perjury --- up to 5 years in state prison --- (Section 837.01, Florida statutes) American LegalNet, Inc. www.FormsWorkFlow.com