DECLARATION OF DOMICILE

STATE OF FLORIDA
COUNTY OF

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, (WE), ________________________________________________________
(please print your name clearly)
became a bona fide resident of the State of Florida on
, 20_ and I
reside at ______________________________________________________________
in the City of __________________________________________________________
My mailing address is: ____________________________________________________
(if different from street address)
My former legal residence was in the City of __________________________________
State of _________________.
(No further statement is required. However, if you wish, you may insert any
pertinent facts such as sale of property or business or relinquishment of employment at
former domicile, removal of family to new domicile, purchase of new home, etc.)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
I FURTHER CERTIFY I will comply with all requirements of a legal resident
of this State. I understand there is a penalty for perjury: perjury is a Felony and is
punishable by incarceration in the State Department of Corrections.

________________________
PRINT NAME

________________________________________
SIGNATURE

________________________
PRINT NAME

________________________________________
SIGNATURE

Sworn to and subscribed before me

this
day of
, 20__. ________________________________________
Notary Public, State of_____________________
My Commission expires:____________________
My Commission Number: ___________________
BY: ________________________________
DEPUTY CLERK