Declaration of Domicile

I hereby declare that I reside in and maintain a permanent residence and domicile at:

Address Line 1
Address Line 2
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State or Region
Zip

Which place of abode I recognize and intend to maintain as my permanent home. I hereby declare that my above described residence and abode in Polk County, Florida constitutes my established, permanent, and full time home, and I intend to continue it permanently as such.

If you receive your mail at a different address than the one you previously provided, please provide us with your mailing address here:

Address Line 1
Address Line 2
City
State or Region
Country
Zip