Free DR-310 - Florida

(To be Completed by Those Estates Claiming Non-Resident Status.)

Domicile Statement

DR-310 R. 12/07
Rule 12C-3.008 Florida Administrative Code Effective 04/09

STATE OF FLORIDA ESTATE OF:

SOCIAL SECURITY #: DATE OF DEATH:

The undersigned, _________________, states that he/she is over the age of eighteen (18); has personal knowledge of the facts set forth herein; and is answering the following questions knowing the Executive Director of the Department of Revenue of the State of Florida will rely on the same. 1. What is your relationship to the decedent?

2. Was the decedent domiciled in Florida at the time of death? yes If yes, do not complete this form.

no

3. Did the decedent ever live in the State of Florida? If so, during what period or periods?

4. Did the decedent live part of the time in Florida and part of the time outside Florida? If so, detail the facts, comparing the size and value of the local and foreign residences and the length of time spent in each location during the five years preceding death.

5. Identify and generally describe each place of residence of the decedent within the last five years preceding death, indicating whether the decedent resided in a house which was rented or owned, apartment, condominium, hotel, nursing home or in a home of relatives or friends. State the assessed and fair market value of the Florida real estate for the year of the decedent's death.

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6. Where and in what years did the decedent vote or register to vote during the five years preceding death?

7. To which state(s) or subdivision(s) thereof and in what years did the decedent pay a tax on real or personal property during the last five years preceding death?

8. Did the decedent file federal income tax returns? If so, where and what was stated therein to be the decedent's residence?

9. Was the decedent employed by or engaged in a business or profession? If so, state when, and the location and nature of same.

10. Did the decedent ever execute a will, codicil, trust indenture, deed, mortgage, lease or any other document in which the decedent was described as a resident of Florida? If so, give the dates and facts, and attach a copy of the last will.

11. Was the decedent a party to any legal proceedings in the State of Florida during the last five years preceding death? If so, explain fully.

12. Did the decedent hold a membership in any religious organizations, clubs or societies in Florida? If so, detail the facts.

13. Did the decedent maintain a safe-deposit box in the State of Florida at any time during the five years preceding death? If so, where was such safe-deposit box maintained?

14. Did the decedent hold a Florida driver's license at any time during the five years preceding death. If so, give dates.

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15. Was an automobile registered in the decedent's name in Florida at any time within five years preceding death? If so, give dates.

16. Was the decedent hospitalized in Florida at any time within five years preceding death? If so, where and when?

17. Did the decedent undergo medical treatment or examinations in Florida at any time during five years preceding death? If so, furnish names and addresses of physicians.

18. Give the place of the decedent's death and burial. Attach a copy of the death certificate.

19. Has the question of domicile been raised in any other jurisdictions? If so, state where, what facts were disclosed, and what decision was reached.

20. If out-of-state domicile is claimed, state the facts relied on to support claim.

21. Give an estimate of the gross value of the estate, wherever situated.

________________________________ Signature ________________________________ Printed Name Social Security Numbers are used by the Florida Department of Revenue as unique identifiers for the administration of Florida's taxes. Social Security Numbers obtained for tax administration purposes are confidential under sections 213.053 and 119.071, Florida Statutes, and not subject to disclosure as public records.