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Affidavit of Domicile
ROBERT S. WERTZ, JR.
Commissioner of the Revenue
(703) 777-0260 Fax (703) 777-0263

1 Harrison St., SE 1 st Floor, PO Box 8000
Leesburg, Virginia 20177-9804
www.loudoun.gov/cor

This form is used to obtain the information necessary for the Commissioner of the Revenue to
make a determination of a person's domicile for local tax purposes. A separate form is required
for each vehicle. Please complete and mail this form to:
Robert S. Wertz, Jr.
Commissioner of the Revenue
Loudoun County
PO Box 8000
Leesburg, VA 20177-9804
“Domicile” means the present, fixed home of an individual to which he returns following
temporary absences and at which he intends to stay indefinitely. No individual may have more
than one domicile at a time.
TAXPAYER INFORMATION
Full Legal Name:

Social Security No:

Current

Date came to

Residence Address:

Loudoun County:

Permanent
Residence Address:

Daytime Phone No:

State where current

driver’s license was issued:

State where registered t