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Declaration Qf Donsicile and ~Citisenahip ~ i
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l TO THE STATS AND COUNTY TAX AS~ESSOA.
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COUNTY. F'I.ORIDA:
This is my declaration of Domicile and Cltizeoahip in the Stste of Florida tLat I am filing diia day in aooord-
anoe~ and in oonfamity with Section 228.17, F7orids Ststu~Ee~. ~
I was formerly a leg,nl resideat of /~7z.~~?TiG G~TY iUd'w ~'~2~',~Y ;
(C~?) ~ ~~0~ z
and I resided at A- C,~o~'~JLvr'~ Ca~i~T _ - However, I Lav~e cbsnged my d~nidle
(Sereat .od Nnmbec)
m and am and Lave been a bona fide reaideat of d~e Scate of Plodda sinoe ~?y ~
,/I~O~MB.~iQ , l~,~and I reaide at lt~te7 .~d~vc~ dF LGtoi1/ ~~P~91J0
(Street and Namber)
~o~T P/.FiPG ~ , s7~. L u c ~ E s Councy, Florida,
(ab)
and this statemeat is to be takea as my declaration of ddzenship, actual 1ega1 reddeaoe and domic3le ia the State
af Flo~ida.
, fama d~omk~ll~e. ram~d d~om~idie~wrrb s ~ a~ea~~ at
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F~LED AND RECORpEpa
ST. LUG~E C~UN1'y-F - .
. RFCORD VERf~1Ep~'~:
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sv1~'
~OGER f~01TRA$
CLERK CiRCUIr COURT'
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I FURTHER CERTIFY that I will re~ster at my loc~l address wbea the regisbratian booka reopen, and
comply with all od~ac requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention bo reteirn bu my forme,~ domicile, and I intead to remain in
~oR~r Pi~Q . sr. c v c ~ f_ r ~,nty, Fioride,
(c~q?)
~~~y ti~~ia~ C- ~~l?~.,,,....~ ~
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y~~ ~vo~-7-„v~/~~ sT
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Sw and s~xibed'before me ~~2L~? day ~ AiQ L/ NG 7~i1/ ~ li~R ~~N/~9 ~.s-
- " ~ A. D.18.~. ~
. ~f~fORM~~v~ !~!/7"~' /N ~l~vr.~FON
, N af F'losda COL ONfL i N 1/.I
; ~ . County ot Arlin~;t,~:. Yir:;~r:~a
MjI t ' MU Cnmmieem., F.~ i i¦iIObE! 2, 1972 1a
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~~`(?o ;be aoecnted in dnp~bs and ari~iual filed witb f~erlc Circroit Ci~urt. ind dapltc~te wkh T~ Asees~or)
s,~„srter.tc re~a.s R .
~OOK~~ Mq~f !
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