Purpose: To request domicile verification from a nonrelative who is familiar with the household's situation. Please list all of the persons living in the home, including the client named on the front of this form: Name.Relationship to Client. This form is used to verify housing information for Texas Health and Human Services. To establish a new domicile, you need 1) a physical presence, and 2) a truthful, concurrent, intent of making the new state your permanent place of abode. How Do I Fill Out an Affidavit of Domicile? Complete an Affidavit of Domicile form. Complete. Residence Address: (as used to register to vote). Number and Street (P.