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Declaration of Domicile and Citizenship
TO THE C7'ATE ANU COUNTY TAX ASSESSOR, ~
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~ - ~ COUNTY, FLORIDA:
This is my deciaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in
accordance, and in conformity with SecCion 222. ! 7, Florida Statutes.
1 was formerly a legal resident of F7~~•~-~p•tii~i_Pdwoo
e~ ,~/S~Ol,c-,~'/ and I
fcitr) <Stace)
resided at ~~~,,L`_L' . Howe~er, I have changed my domicile to
(Street snd NumAer)
~nd am and have been a bona fide resident of the State of Florida since day of
~id/~/ L , 19.~, and l reside at 7~C ~Q'iYL= ~Lt /E~~S
~ ~ (Street and Numbet)
~~T ~ ~ , County, Florida,
(c~~r)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
- (Insert here any peYtineot facts; such u sale of property or business, or relinquishment of employment at former ~
domicile, removal oi family to new domicile, purchase of home, etc,)
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~C/~~~ /~i~~/'e- /~i~//~
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f EO AMO R~C~
~~1.~1.CtE CQtllff~~?
ROCER P01~~;
CLERK CIRCUIT Cp1{K
RECORO YEpIFfEO..~~
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I FURTHER CERTIFY thai I will register at my local address when the registration books reopen, and
comply with a!1 other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
_ .
~ sT .c ~ c y~t , countY,
Florida, permanently. (c;~r)
To AN ~3. FV~+ NS
(Nsme)
/G 7 a~° ,C~ri,
(Addras)
Sworn to and subscribed before me this day of .~r
~~~lKtltlt •t'
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A.D. 19~~ ~ b.,!~;~
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ot biic State of Fbrida at lat '-S '
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My Commission expires ~ - ~ ~ ~ csl~i~ t ' ~ ~ f.~
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(To be e:ceuied in duplicate and original fJed with Cierk Circuit C~ ~'with Tax Assessor)
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