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S'.I_UC!~ Jl1NTY. l
Declorotion bf Domici~e- on~ ~itisenship
TO THE STATE AND COUNTY TAX ASSE.9SOIt,
3T _ I.IIC?F. - COUNTY, FLORIDA;
This is my declaration of Domicile and Citisenahip in the State of Florida that I am filing this day in
accordance, and in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of----ROCS'j$S7,'ER------------------------- - - ~ -----I~7~- -------------------------
47 T.i nnnl (City) (8tate)
an,. I resided at ---" --II ~~:
~ ----_-- -------------------_-- However. I have changed my domicile
(street sad Nnmtrer)
tp anLl aP_'! Ark hAyt? l~Pn a Ix~nu Rde reairlgnt ~f tl:~ ~~., ~t° ~f ~:^.^,u:. SIZ:C~ 2i0ti~1 - ---..i8y Of
.Twine ou Fit . ~ >3oz 5(315-Santa Rosa Parkwby
-----..------ . 19------- ~ and I reside at_- -------------------------------- -- ------ ---- --
i.,txaeinle~txi rayric :~»~: ~••:::~:::::~:
- F~~..p~~R~E----- ----------------------------------------. -----HT..LUCIE---------------- ---- -----County, Florida,
---------------------
(City)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in
the State of Florida.
(insert here any pertinent facts, such as sale of property or business. or relinquishment of employment at
former domicile, removal of family to new domicile, pnrchasa of home. ett.)
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.....' •t~~ ~. _ ~ _ .. .. 1 1 . 1
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I FURTHER CERTIFY that I will register at my local address when the registration books reopen,
, - ,. rim ~.» _tt-, _ :y%3"i~ ~ i1f .°. lr~*~l ~g;a t t Q ±n
--- --- .: -- _ - ~- -- -, ..~: ,.... ~ cr. cf his .,ts
I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain
in -- -- - -- F'T-, - PIERC_L~---- - - -- --- --------- - --------- - ---------------- ST.-----I+UCIE -------- - - ._County, Florida,
(City)
permanently. ~1~~1 _~~'---111_~~~`i_'- - --------------
- - ~ ---
(Name i
,f ~ ~L) l i r
Swo~i tti slid-aubecribed before me this_....__18 day of
- ~.
,.
_ ._
' ,. ~.
~ ~":~:
. ~.,.
~~ ~ CLE CIRCIIIT COURT
---- --~~Miitiis-----~r-----JAJ..Dm------------------------------------
(Addresa)
Dep. Clerk
(To be executed in dup.
Rn..on BnoDly l'o.. Flent l'itr. Fln.
original Sled with ('lerlc Cireuit Court, and duplicate with Taz Assessor)