After Recording Return to: ______________________ ______________________ ______________________ DECLARATION OF DOMICILE To the Clerk of the Circuit Court [County Comptroller] ________________________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. FOR DOMICILIARIES OF THE STATE OF FLORIDA: I hereby declare that I reside in and maintain a place of abode at: __________________________________________________________________________________ (Street and number) ____________________________________________________________________________, Florida (City and County) 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 herby 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 making this declaration, a bona-fide resident of the State of Florida residing at: __________________________________________________________________________________ (Street and number) ____________________________________________________________________________, Florida (City and County) and have been a permanent resident since ______________________________________________. M onth/Day/Year I formerly resided at: ___________________________________________________________________________________ (Street and number) ___________________________________________________________________________________ (City and County) and the place or places where I maintain another or other place or places of abode are as follows: (Here list street address, city, county and state of any other place or places of abode.) ____________________________________________ (Signature) State of Florida County of Lake Sworn to (or affirmed) and subscribed before me this _________ of _________________________________, by M o nth/Year ____________________________________________________________________. ____________________________________________ (Signature of Notary Public) personally known ____ or produced identification ____Ty pe of identification produced ______________________________. American LegalNet, Inc. www.USCourtForms.com