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 Statutes. FOR DOMICILIARIES OF THE STATE OF FLORIDA: I hereby declare that I reside in and maintain a place of abode at: _______________________________________ (Street Address) _______________________________________, Florida __________ (City and 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 principle 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 Address) _______________________________________, Florida ___________ (City and County) (Zip Code) I formerly resided at: _______________________________________ (Street Address) _______________________________________, ____________________________ (City and County) (State and Zip Code) and the place or places where I maintain another or other places of abode are as follows: (Here list street address, city, county, and state of any other place or places of abode ) _________________________________________________ Print Name _________________________________________________ Signature STATE OF FLORIDA COUNTY OF ___________________ Sworn to (or affirmed) and subscribed before me this ________ day of _____________________, 20 _______ by ___________________________________________. _______________________________________________ Signature and Title of Notarizing or Attesting Official _______________________________________________ (Print, type or stamp commissioned name of Notary Public) Personally known ________ OR Produced Identification ________ Type of Identification Produced: ____________________________ American LegalNet, Inc. www.FormsWorkFlow.com