Name of state of your claimed legal residence: _________________________. I am and have been a domiciliary resident of.All students taking credit classes must complete the. Domicile Determination Form. How to fill out the Residency Domicile Determination Form Virginia? Spouse's Domicile: Choose this option if you are married and want to claim eligibility for in-state tuition based on your spouse's domicile. For the past 12 months, has the above person lived out-of-state, worked in Virginia, and paid Virginia income taxes on at least. How Do I Fill Out an Affidavit of Domicile? Full Middle. Last. (mm). (dd). (yy). 2. Must demonstrate three requirements of Virginia domicile for one year prior to the term for which entitlement is sought.