DECLARATION OF DOMICILE To the Clerk of the Circuit Court (County Comptroller) of POLK 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 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) , Florida (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) Sworn to and subscribed before me this of , . (Signature of Notary Public, State of Florida) (Print, type or stamp commissioned name of Notary Public) Personally Known (Check One) or Produced Identification Type of Identification Produced: (See reverse side for Domiciliaries of States Other than the State of Florida) American LegalNet, Inc. www.FormsWorkFlow.com FOR DOMICILIARIES OF STATES OTHER THAN THE STATE OF FLORIDA: I hereby declare that my domicile is in the State of and that I intend to permanently continue and maintain my domicile in such state. At the time of making this declaration I am a bona fide resident of the State of . . My place of abode within the State of Florida, if any, is as follows: (Here list street address, city, and county of place of abode in Florida.) (Person making declaration may also include such other and further facts with reference to any acts done or performed by such person which such person desires or intends not to be construed as evidencing any intention to establish his/her domicile within the State of Florida.) (Signature) Sworn to and subscribed before me this of , . (Signature of Notary Public, State of Florida) (Print, type or stamp commissioned name of Notary Public) Personally Known (Check One) or Produced Identification Type of Identification Produced: Rev. 7/2011 LS American LegalNet, Inc. www.FormsWorkFlow.com