DECLARATION OF DOMICILE To the Clerk of the Circuit Court Martin County, Florida. This is my declaration of domicile in the State of Florida that I am filing this day of , 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 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 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 making this declaration, a bona fide resident of the State of Florida residing at: (Street and number) Florida (City and county) I formerly resided at: (Street and number) (City and county) (State) 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.) ____________________________ (Print name) __________________________ (Signature) . Sworn to and subscribed before me this_____day of ___________ _____, 20 ______________________________________________ Signature of Notary Public/Deputy Clerk, State of Florida ______________________________________________ Print, type or stamp commissioned name of Notary Public Personally known________ or (check one) Produced Identification___________ Type of Identification Produced: American LegalNet, Inc. www.FormsWorkFlow.com