DECLARATION OF DOMICILE

This is my Declaration of Domicile in the Commonwealth of Puerto Rico that I am filing this day in accordance and in conformity with the law.

I, [FULL NAME], became a bona fide resident of the Commonwealth of Puerto Rico on [MONTH] [DATE], [YEAR], and I reside at and maintain an abode at [STREET ADDRESS], [APARTMENT NUMBER], [CITY], Puerto Rico [ZIP CODE], which I recognize and intend to maintain as my permanent home.

My former residence was in the City of [CITY], [COUNTY] County, [STATE].

I further certify that I have complied or intend to comply with all requirements of a legal resident of the Commonwealth of Puerto Rico.

Under penalties of perjury, I have executed this document this [DATE] day of [MONTH], [YEAR].

Signed, sealed, and delivered

in the presence of:

____________________________	_________________________________

[FULL NAME]

____________________________

Witnesses

Sworn by [FULL NAME] at [LOCATION], this [DATE] day of [MONTH], [YEAR], before me.

______________________________________

(SEAL)	Public Notary/Commissioner of Oaths/Solicitor