Fillable DECLARATION OF DOMICILE To the Clerk of the (Pinellas County Clerk of the Circuit Court and Comptroller)

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DECLARATION OF DOMICILE To the Clerk of the (Pinellas County Clerk of the Circuit Court and Comptroller)

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DECLARATION OF DOMICILE
To the Clerk of the Circuit Court County Comptroller of County, Florida.
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.
FOR DOMICILIARIES OF THE STATE OF FLORIDA:
I ________________________ hereby declare that I reside in and maintain a place of abode at:
(street and number)
, Florida
(city and county)
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 am, at the time of making this declaration, a bona fide resident of the State of
Florida residing at:
(street and number)
, Florida
(city and county)
I formerly resided at:
(street and number)
, Florida
(city and county)
and the place or places where I maintain another or other place or places of abode are as follows:
(Here list street address, city, county, and state of any other place or places of abode.)
(Signature)
Sworn to and subscribed before me this ____ of ____________________, ______.
_______________________________________
(Signature of Notary Public, State of Florida)
(Print, type or stamp commissioned name of Notary Public)
Personally Known or Produced Identification
(Check One)
Type of Identification Produced:
(See reverse side for Domiciliaries of States Other than the State of Florida)
Rev. 1/2017 LS
FOR DOMICILIARIES OF STATES OTHER THAN THE STATE OF FLORIDA:
I ________________________ hereby declare that my domicile is in the State of ___________ and that I
intend to permanently continue and maintain my domicile in such state. At the time of making this
declaration I am a bona fide resident of the State of ___________. My place of abode within the State of
Florida, if any, is as follows: (Here list street address, city, and county of place of abode in Florida.)
(Person making declaration may also include such other and further facts with reference to any acts done
or performed by such person which such person desires or intends not to be construed as evidencing any
intention to establish his/her domicile within the State of Florida.)
(Signature)
Sworn to and subscribed before me this of , .
(Signature of Notary Public, State of Florida)
(Print, type or stamp commissioned name of Notary Public)
Personally Known or Produced Identification
(Check One)
Type of Identification Produced:
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DECLARATION OF DOMICILE To the Clerk of the (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 9 February 2021

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