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~'orm~~. T. 1r601.D-(60Y-.t-28-b?) ~~1? .
Declaration of Domicile and Citisenship ~
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TO THE STATE AND COUNTY TAX ASSESSOIt. • ~1~y,~ ~
. L~a c ~ e COUNTY. FLORIDA : 3
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Thia is my declarAtion oi Domicile and Citizenahip iu the State of Florida that I am fllin~ thia day in ~ ~
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accordance, and in conformity v?ith Chs~pter 222~ Section 222.17, Florida Statutea.
I waa former~v s le reaident oi__~~-~ ~
Y ~ ~f? v~..j ~i ~ " a_ -v J " '
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((,1q) ~ (Saa)~
and I resided at_~z1.-.a.:-=~#~~:<.- However. I have chan~ed my domicile
(3trwt aad Number)
to and sm and have been a bona Rde reaident of the State oi FloridA eince..._.== . day of
~-~---~-~--e 1971 . and I t@Sld@ a~-• I=--- =~=1t.---7=~ y~ ~T~'-~' • ::L :ti. .~:`+1; ~
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( Strwt and Nnmbz) '
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-_--------___._-------._..._(7ounty, FlOrida,
(ctcy)
and thia atatement is to be tvicen as my decl~?ration of citizenship, actual leQal reaidence and domicile in
the State oi F7orida. ~
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Insert bera W wrtin~nt i~Ma. wch as W?l~ oi~ropar y a~ o~,) u~pyislm~nt o~ ~mplOymprt ~t
oraa~= domieib. r~a?o~ral ot f~mi1~ to n~w dom Aut~ch~a~
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I FLTRTHER CEATIFY that I will re~ister at my local addresa when the re~istrstion booka reopen~
and comply with all other requirementa oi a le~al resident oi thi~~ Stste. ~
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I FIJRTHE~t CERTIF'Y tbst I hove no intention to ntura to my former domicile. and I intend Lo r~emain
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pei:.-lanently. ~ ~ . ~
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_ Sworn to ~•si~~,,,~,.~;~ before me thi~__~ _...---day o!
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~1y COri7lif~i1~71 ~ . ' • ti
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, (To b~ eY~eutad i~ d~11aN u~d ~risinal ~l~d w?itb q~rlc Ginvit Conrt. asd d~olksq wit6 Tat AwMOr) E
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