DECLARATION OF DOMICILE TO THE STATE OF FLORIDA AND COUNTY OF MIAMI-DADE: 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. I,__________________________________ was formerly a legal resident of ______________________ Print Name City ____________, and I resided at ___________________________________, however, I have changed my State Street Address Domicile to and have been a bona fide resident of the State of Florida since the____day of________,_____. I now reside at _____________________________________,_________________________________. Street Address City Miami-Dade 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 must purchase Florida license plates for motor vehicles, if any, owned by me, and/or my spouse; if I vote, I must vote in the precinct of my legal domicile and that my estate will be probated in the Florida Courts. I was born in the U.S.A.: Yes____ No____Place of birth:__________________________________________ Naturalized citizen - Where:___________________ Date: _______________ No.______________________ Lawful Permanent Resident: Date: _____________ No. __________________________________________ ________________________________________ Signature ________________________________________ Print Name _______________________________________________ (Mailing Address) STATE OF FLORIDA COUNTY OF MIAMI-DADE Sworn to and subscribed before me this _______ day of ________________________, _______. _______________________________________________ Notary Public State of Florida at Large/or Deputy C lerk _______________________________________________ Print, Type or Stamp name of notary Type of I.D. Produced # __________________________________________________. Penalty for perjury: up to five (5) years in State Prison and $5,000 fine (F.S. 837.02) CLK/CT 578 REV. 12/07 Clerk's web address: www.miami-dadeclerk.com American LegalNet, Inc. www.FormsWorkflow.com