STATEMENT OF DOMICILE STATE OF ) ) ) COUNTY OF ss: The undersigned, being first duly sworn, deposes and states as follows: That , at the time of making this statement, is a bona fide resident and domiciliary of the State of Nevada, and established said residence on the day of , 20 . 1. That 2. That said residence in Nevada constitutes predominant and principal home, and resides and maintains a residence in Clark County, Nevada, at: intends to continue it as predominant and permanent home. 3. That was formerly a resident of: (list all former places of residence) 4. That currently maintains other residences, outside the State of Nevada (not predominant or principal) at: 5. That makes this sworn statement pursuant to Nevada Revised Statutes 41.191 through 41.197. Further affiant sayeth naught. I declare under penalty of perjury under the law of the State of Nevada that the foregoing is true and correct. EXECUTED this day of , 20 . _____________ Affiant File: Clerk of the Court 200 Lewis Avenue, 3rd Floor Las Vegas, Nevada 89155 Fee: $5.00, Original and Two (2) Copies Statement of Domicile2/16/2007 American LegalNet, Inc. www.FormsWorkflow.com NRS 41.191 Declaration of domicile in Nevada 1. Any person who has established his domicile in the State may manifest and evidence his domicile by filing in the office of the clerk of the district court for the county in which he resides, a sworn statement showing that he resides in and maintains a residence in that county, which he recognizes and intends to maintain as his permanent home. 2. Any person who has established a domicile in this state, but who maintains another residence in some other state, may manifest and evidence his domicile in that state by filing in the office of the clerk of the district court for the county in which he resides, a sworn statement that his residence in Nevada constitutes his predominant and principal home, and that he intends to continue it permanently as his predominant and principal home. 3. A sworn statement filed pursuant to this section must contain, in addition to the declaration required in subsection 1 or 2, a declaration that the person making the statement is at the time of making the statement a bona fide resident of the state, and it must set forth his place of residence, the city, county and state in which he formerly resided, and all other places, if any, in which he maintains a residence. NRS 41.193 Declaration of domicile in other state. 1. A person who: (a) Is or was domiciled in a state other than Nevada and who: (1) Has a residence in Nevada; or (2) Does or has done acts within Nevada which, independently of his actual intention concerning his domicile, might be taken to indicate that he is or intends to be domiciled in Nevada and; (3) Desires to maintain or continue his domicile in a state other than Nevada, may manifest and evidence his permanent domicile in that other state by filing in the office of the clerk of the district court in any county in Nevada in which he has a residence or in which he may have performed those acts, a sworn statement that his domicile is in a state other than Nevada, naming the state and stating that he intends to permanently continue his domicile in that state. 2. The sworn statement filed pursuant to this section must contain, in addition to the declaration required in subsection 1, a declaration that the person making the statement is, at the time of making the statement, a resident of a state other than Nevada, and it must set forth a place of residence which he maintains in the state or the fact that he does not maintain a residence in Nevada. It must also set forth other facts with reference to any acts done by him which he desires not be construed as evidencing an intention to establish his domicile in Nevada. NRS 41.195 Signing and recording of declaration; fee. The sworn statement permitted by NRS 41.101 and 41.193 must be signed under oath before a person authorized to administer oaths. The clerk of a district court in whose office a statement is filed shall record in a book provided for that purpose, and collect a fee of $5 for performing that duty. NRS 41.197 Other methods of providing domicile not repealed or abrogated. Nothing contained in NRS 41.191 to 41.197, inclusive, repeals or abrogates any existing method of providing domicile. Statement of Domicile2/16/2007 American LegalNet, Inc. www.FormsWorkflow.com