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Declaration Of Domicile For Purposes Of Notary Public Application

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Arkansas Secretary of State

ark

artin

State Capitol • Little Rock, Arkansas 72201-1094

501-682-3409 •

Business & Commercial Services, 250 Victory Building, 1401 W. Capitol, Little Rock

Declaration of Domicile

For Purposes of Notary Public Application

(If you are a United States citizen, do not complete this form.)

This Declaration must be: (1) Notarized — (2) Filed for record with the Circuit Clerk in the

county where you reside — (3) Attached to your notary public application.

I, ____________________________________, hereby declare that I reside in and maintain a

place of abode at:

_________________________________

____________________________________

Street & Number

City, State & ZIP Code

which place of abode I recognize and intend to maintain as my permanent home and, if I maintain

another place or places of abode in some other state, I hereby declare that my above referenced

residence and abode in the State of Arkansas constitutes my predominant and principal home, and

intend to continue it permanently as such.

_______________________

________________________

__________

Printed Name

Signature

Date

Notarization

State of Arkansas

County of __________

Subscribed and sworn before me, a Notary Public, on this ___day of ___________, _____.

_____________________

________________________

Signature of Notary Public

My commission expires:

Circuit Clerk filing

Sworn and subscribed to before me, _______________________, Circuit Clerk in and for the

County of __________________, State of Arkansas, on this _____ day of ____________, _____.

______________________________

(Signature of Circuit Clerk)

Rev. 4/06

Declaration Of Domicile For Purposes Of Notary Public Application

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