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Declaration of Domicile and CitizensltipT. LUC/f COUNn. rLA.
TO THE STA'l'E AND COUN'!Y TAX J.SSJtSSOR,
_~~uc1e COUNTY, FLORID!..;
Thia ia my declaration of Domid1e aDd CitUeDabi!) in the State of FIorid.l that I am dU~ this day in
accordance, and in conformity with Chapter 222, Soction 222.17, Florida Statute!!,
1 was formerly a lep} reaident oL___.~_'.}.QQ-~~_.~.~Jg.lJff.~.t---Q~.~~~,_.~~_y~~,~-.M.9-!?-,~~:~.~l...2.,.--Qanada
(Cit)') (Stat.)
and I reoided aL.3,a60"Baule..var.o...Lf!.v.ea.qU8..-----,--------.....,., Howeyer, I have chana'ed my domieile
(Stree, aDd Number)
to and am and have been a bcna tide reaident of the State of Florid" l5ince_.....7til___,....._...,_________clay of
---.--.-lllGUST____._____,__ ________._____._, 19..,-5-9 and I reeide a t..____!).Q~__'!.h.~~__.r..Q.~!!~__ Dr.!!~___.___________.__,...
. (Street aDd Number)
_on --______E.QJ:J..__.f ;t~~~. ~_-..----_.--_----,... ,,_.. " ----, .--"-~- t.L~y'~j..~.___._ '__n -----..- -, -.---- ----. County, Florida,
(Cit)')
and this statement is to be taken as my declaration of citizenahip, actual lei8l residence and domicile in
the State of F1orida.
(lnMn here !IJ1Y pertinent facta. .uc:h u aale ofpropertl or blaiDeaa. or relinquiahment 01. IIDploYlMDt at
fOnDer domlclle. rem(;val of famil, to n.. domicile, purchaa. of bom.. -.}
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I FURTHER CERTIFY that I will regist.er at my local addrets8 when ihe reptration books reopen,
and comply with all other requirements of a legal reeident of this State.
I FURTH~~ CERTIFY that I have no intention to return to my former domicile, and I intend to remain
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in._l'.cy"~-=~r-t~r~!.{"'.,.-...--. ----,---,----------.. __. --. ,-.. .-- -..--,
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Sworn to .$ct~~ before me tt.i!L_9_th.u.y of
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___,____~~_~~!.:~._:___..,__,___.__, A. D, 19_~!
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.-----7-.~.Pd;i:~-it~t.-~ 1i'Ift!'VIa.t ,.... ~ .
._~!_~..._ ______________"._______._ County, Florida,
My Com.mi88ion expirel_______._.
(To be exeeuted In duplicate and orlcinal ftMd wiUl <le.>>k CbevJt Coc..'t, ud clup!ieate witll Tu AaMu9..)
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