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Declaration of Domicile and Citi2:enship
TO THE STATE A:\D CUl;i",TY TAX ASSESSOR.
~./i'. LU:~] ~
COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florid:'. that ~m filing this day III
accordance, ami in \:onf('rmity with Chaptl'r :222, Seetion 222.11, Florida Statutes,
I was formerly a legal resident of
~:1JLD:~: .,,;'~ur
VA..
(City)
(State)
I have changed my domicile
XZlOU15th day of
and 1 resided at
~('r.. U01.
However,
(Street anu ~umheT)
to and al"l and han' been a lJona flde resident of thl' :->tatl' of Florida sine.'
j 'f ' ~ : 1 !
.. vi.,
.~~
. l~ cC) , and I reside "t
4702:-:1m Aye (';ihite,.City)
(Street anu Number)
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County, Florida,
ICity)
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,,;' I this statl'ment is to Ill' taken as my declaration of citizenship, actual legal residence and domicile III
,..e :--tatt' uf Florida,
\llIsen here allY pertin"llt facL;, such as ,ale l,f prq,<:rty or business. or relinQui~hment of emp!uyment at
former domicil!:', removal of family to new domieile, purchase of home. etc,)
.
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I Fl'I:TlIEI: ('EKTIFY that I will regi~ter at my local address when the rcgi~tration hooks reopen,
and comply with all othf'r re<j\,in'mf'nts of a iq;al resident of this State,
I Fl'RTlIEIt CERTIFY that 1 ha\"c no intention to retum to my fomler domicile, and I intend to remain
III
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County. Florida,
(City)
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(Name)
pf'rmanently.
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(Addre!~ )
Swom tD and wLfcrited before me this :' 1 day 0"
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, A. D. 1961
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(To be executed in duplicate and orii:'inal i'iled ",;th Clerk Circuit Court. and duplicate with Tax ^!~e~sor)
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