DECLARATION OF DOMICILE - Bay County

1 DECLARATION OF DOMICILE This is my DECLARATION of DOMICILE in the State of Florida that I am filing this day in accordance and in conformity with Section , Florida Statutes. I hereby declare that I became a bona fide resident of the State of Florida on: _____(date of arrival) I am, at the time of making this DECLARATION , a bona fide resident of the State of Florida residing at: (street and number) (city) (zip code)

2 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 or states, I hereby declare that my above-described residence and abode in the State of Florida constitutes my predominant and principal home, and I intend to continue it permanently as such. I formerly resided at: (street and number) (city) ( County ) (state) and the place or places where I maintain another or other places of abode are as follows.

3 (street and number) (city) ( County ) (state) (street and number) (city) ( County ) (state) 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; if I drive, I must have a Florida drivers license; if I vote, I must vote in the precint of my legal DOMICILE , and that my estate will be probated in Florida courts.

4 _____ _____ (Signature) (Signature) Print Name_____ Print Name_____ ID Produced_____ ID Produced_____ ( ) United States Citizen ( ) United States Citizen ( ) Citizen of_____ ( ) Citizen of_____ Green Card #_____ Green Card #_____ Date of Issuance_____ Date of Issuance_____ STATE OF FLORIDA County OF BAY Sworn to and subscribed before me UNDER OATH this _____ day of _____, 20____. _____ Signature of Notary Public, State of Florida To be filed with the Bay County Clerk of Circuit Court Penalty for perjury: up to five (5) years in state prison and $ fine: Chapter.