United States Military personnel must complete this page in addition to pages 1-4 of the General Domicile Questionnaire. Purpose: To request domicile verification from a nonrelative who is familiar with the household's situation.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? For the past twelve months, has the above person lived out-of- state, worked in Virginia, and paid Virginia income taxes on at least. How to fill out the Residency Domicile Determination Form Virginia? For the past 12 months, has the above person lived out-of-state, worked in Virginia, and paid Virginia income taxes on at least.