________________________________________________________
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DECLARATION OF DOMICILE
TO THE STATE OF FLORIDA AND
COUNTY OF MIAMI-DADE:
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, ____________________________________________ was formerly a legal resident of ________________________________
(Print Name)
(
City)
_____________________and I resided at ___________________________________________________, however, I have changed my
(State) (Street Address)
Domicile to and have been a bona fide resident of the State of Florida since the _____day of_____________________, 20_____. I now
reside at ________________________________________________________, _____________________________.
(
Street Address) (City)
Miami-Dade 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 must purchase Florida license plates for motor vehicles, if any, owned by me, and/or my
spouse; if I vote, I must vote in the precinct of my legal domicile and that my estate will be probated in the Florida Courts.
I was born in the U.S.A.:
Yes No
Place of Birth: _______________________________________________________
Naturalized Citizen - Where: _______________________
Lawful Permanent Resident: Date: _________________
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
Date: _____________________ No. _____________________________
No . _______________________________________________________
(Signature)
(Print Name)
(
Mailing Address)
Sworn to and subscribed before me this _______ day of ____________________________, 20_______,
by __________________________ personally known to me or who has produced a _______________________ as
identification and did take an oath.
Signature of Notary Public, State of Florida
Print, Type or Stamp name of notary
You are required to fill-out and notarize the form. When complete, bring or mail original to the County Recorder’s Office at 22 NW
1
st
St., Miami, Florida 33128 with a $10 (money order or cash if coming in person) with a self-addressed stamped envelope.
Penalty for perjury: up to five (5) years in State Prison and $5,000 fine (F.S. 837.02)
CLK/CT 578 Rev. 08/16 Clerk's web address: www.miami-dadeclerk.com
