Form Dr-310 - Domicile Statement (Page 3 of 3) in pdf

Form Dr-310 - Domicile Statement Page 3

DR-310

R. 10/09

Page 3 of 3

15. Was an automobile registered in the decedent's name in Florida at any time within five years

preceding death? If so, give dates.

16. Was the decedent hospitalized in Florida at any time within five years preceding death? If so, where

and when?

17. Did the decedent undergo medical treatment or examinations in Florida at any time during five

years preceding death? If so, furnish names and addresses of physicians.

18. Give the place of the decedent’s death and burial. Attach a copy of the death certificate.

19. Has the question of domicile been raised in any other jurisdictions? If so, state where, what facts

were disclosed, and what decision was reached.

20. If out-of-state domicile is claimed, state the facts relied on to support claim.

21. Give an estimate of the gross value of the estate, wherever situated.

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Signature

________________________________

Printed Name

*Social security numbers (SSNs) are used by the Florida Department of Revenue as unique identifiers

for the administration of Florida’s taxes. SSNs obtained for tax administration purposes are confidential

under sections 213.053 and 119.071, Florida Statutes, and not subject to disclosure as public

records. Collection of your SSN is authorized under state and federal law. Visit our Internet site at

and select “Privacy Notice” for more information regarding the state and

federal law governing the collection, use, or release of SSNs, including authorized exceptions.

Form Dr-310 - Domicile Statement Page 3