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Declaration of Domicile and CitiJ;ensYi~uCIE CDUHH\ rlA.
TO THE STATE AND COUNTY TAX AS8F..~R,
COUNTY, FLOlUDA:
Thia is m~ declaration of lXlnUcile and CitheOl-hip in the State of Florida that I am 1\iinr this day in
accordance. and in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a le~l resident of________-.Y1r.gitL___oo_______mmm_m_____________, m___Ken~q,----m-----
(Cit7) (Stat.)
and I reaidoo ai."... P. O.Bo~'s~f~-N'~b;r)h-----------'h--'---' However, I have changed my domie:Ie
to and am and have been a bona fide resident of the State of Florida since__", 10th,:, '",moo day of
_ '00 ,s. e,pt, ernbe_:r________oo__.., __u_____" 19__hm~nd I reaide a L. __l902___S .D---J.4 th ____St.r_e1i t__, ___m_~___.,___m.___'___
(Stnet and Number)
____,______,. r<U:.t__J) l~,:r~~____oo,__ __mm_____mmm" .____,_, m'__~h~\!.~l~m____mmm______, _____________, County, Florida.
(City)
and this statement is to be taken as my declaration of citizenship, actual legal residence 1L~d domicile in
the State of Florida.
(haert here &"11 pertinent facta. IUch .. l&1e 01 prop6rt)' or buainea.. or rellnQuiahment c~ employmlDi at
former domicile. removal of famil7 to new domlcUe. purch... 01 home. etc.)
Establishing residence
93093
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PL~r I~~~Q Rr.COROEO
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ROGER POITR,\:. ' ~,.,
("- ; ~ .'>lr ~'''''\'~1. ::-~:.;t\.f:A
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I FURTHER CERTIFY that I will registe..- at my local addre88 when the re~tn.tion books reopen,
and comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I bave no inumtion to retunl to my former domicile, and I intend t.o remain
pennanently.
__ ____.__.B_t . T .\1 C i e .__m ___m________ _m_'_ __County, Florida,
~-4f~.---,,-~,------,-------
(Name)
Charle~ 6alhoun
in. __om ___ ____ __", ,_" _. for,t.._ Pierc a ___ ,____ _, ,m___ m ___. ____u__,
(Ctt)')
(Addre..)
_:~~t:i:i-~':~T~:~Y=61 ~cl~~i:tj':~:ti~:>
ot&ry Public Stau of Florida ai ~ 6l.' >\,',',~,~>('::-...:,~, ' ~,~ ,,:" . .~.',~,:~ "
My Con:unission expires__ ___mm__~_~__12___~-- , ,
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(To be executed in duplicate and orirtnal ti'e<! with CItr~."Qrea'.t ~/~'~\~ with Tax Aueu9r)
Rn..'" 80DDI,. Co,. Plant Cll)', Fla,
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