JOSEPH E. SMITH Clerk of the Circuit Court, St. Lucie County Recording Department 201 S. Indian River Drive Fort Pierce, Florida 34950 (772) 462-3207 DECLARATION OF DOMICILE To the Clerk of the Circuit Court of St. Lucie 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 GENERAL INFORMATION / PLEASE PRINT CLEARLY First Name Permanent Street Address Permanent City State Middle Name Last Name Florida Zip I hereby declare that I reside in and maintain a place of abode at the above address, which 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: Current Street Address Current City State Florida Zip I formerly resided at the below address 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.) Former Street Address Former City Former State Former Zip Signature Sworn to and subscribed before me this day of month , 20 JOSEPH E. SMITH, CLERK OF THE CIRCUIT COURT, ST. LUCIE COUNTY, FLORIDA By: Deputy Clerk (Print, type, or stamp commissioned name of Notary Public) (Signature of Notary Public, State of Florida) (Seal) Personally Known or (Check one) Produced Identification Type of Identification Produced: Rev. 11/29/2016 American LegalNet, Inc. www.FormsWorkFlow.com