Declaration Of Domicile Form - Florida

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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 Statues.
I _________________________________________________________ was formerly a legal resident of
(please print name)
and I resided at ____________________________________ however,
(city and state)
(street address)
I have changed my domicile to and am and have been a bona fide resident of the State of Florida since the
________ day of __________
I now reside at __________________________________________
,20 ______ .
(street address)
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 am subject to intangible taxes; I must purchase Florida license
plates for motor vehicles, if any, owned by me and/or my spouse; I must vote in the precinct of my legal domicile (if
I vote), and that my estate will be probated in the Florida
I was born in the USA: Yes_________ No______ Place of birth:
Naturalized citizen ______ Where: __________________________ Date:_________ No.: _______________
Permanent Visa: Yes ________No _____ Date ___________ No.: __________________________________
State of Florida
County of CLAY
Signature as printed above
Sworn to (or affirmed) and subscribed
before me this ______ day of _________
by _____________________________________
Mailing address
____ Personally known
City / State / Zip
____ Produced identification
(type of identification)
(Signature of Notary/Deputy Clerk)
(Type or print name)
Penalty for perjury --- up to 5 years in state prison --- (Section 837.01, Florida statutes)


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