DECLARATION OF DOMICILE ***** TO THE STATE OF FLORIDA AND COUNTY OF HERNANDO ***** This is my\our declaration of domicile in the State of Florida that I\we are filing this date in accordance, and in conformity with Section 222.17 Florida Statutes: I\We, NAME was\were formerly a legal resident of: FORMER STREET ADDRESS CITY STATE ZIP However, I\we have changed my\our domicile to the following address in Hernando County, FL CURRENT STREET ADDRESS CITY STATE ZIP and this statement is to be taken as my\our declaration of actual legal residence and permanent domicile in this State and County to the exclusion of all others, and I\we will comply with all requirements of legal residents of Florida. " I\We understand that as a legal resident of Florida I\we are subject to Intangible taxes; I\we must purchase Florida license plates for motor vehicles, if any, owned by me or my spouse; I\we must obtain a Florida driver license, if I\we drive; I\we must vote in the precinct of my legal domicile (if I\we vote); and that my\our estate will be probated in the Florida courts. " I was born in U.S.A.: YES Spouse: YES NO BIRTHPLACE: NO BIRTHPLACE: NATURALIZED CITIZEN: Where: DATE: NUMBER: ______________________ YES NATURALIZED CITIZEN: Where: DATE: NUMBER: _______________________ YES PERMANENT VISA: DATE: NO DATE PERMANENT VISA: DATE: NO DATE NUMBER: ______________________ NUMBER: ______________________ Hernando County Residency: ______________________________________________________ SIGNED Hernando County Residency: ______________________________________________________ SIGNED STATE OF FLORIDA COUNTY OF HERNANDO Sworn to and subscribed before me this produced who did not take an oath. day of , 20_____, by who has as identification and ______________________________ NOTARY SIGNATURE R­ Hernando County Property Appraiser ______________________________ NOTARY SEAL American LegalNet, Inc. www.FormsWorkFlow.com