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Deciaration of Domicile and Citiz~p
TO TH~ STATE AND COUNTY TAX ASSESSOR, ~1~ .
.
' -«<-~-Q _ COUNTY, FLORIDA:
This is my dcclaration of Domicile and Citizenship in the State of Florida that t am filing this day in
accordance, and in conformity with Section 222.1 Ftorida Statutes.
1 was formerly a legal resident of ~ Ac.rr-~?%JAts ~ 'VEw and 1 ~
(CitY) (Stale)
resided at o A~. ER r o~v s~- - . However, 1 have changed my domicile to
(Stteet and Numbcr)
and am and have been a bona fide resident of the State of Florida since day of
-~'1 N'R , 19~
1____, and l reside at L '~°"r ~~sF dL vd •
(Street snd Number)
Fr_ ~~E ~eeE T L~, e. F ~ County, Florida,
(c~iy)
and this siatement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida. ~
(Insert here any pertintnt facts, such as sale ot property ot business. or relinquithment ot empbyment ~t totmer
domicile, removal of hmilr to new domicile. purchase of hoaie, etc.)
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RECOAORVEA FIED~U
~ 15~'~l
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104
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I FURTHER CERTIFY that I wiil register at my local address when the registration books reopen, and
~ comply with aU other requirements of a lega! resident of this State.
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! I FURTHER CERTIFY that 1 have no intention to return to my former domicile, and I intend to remain in
~ .
i fT . /'iEie~e ~ _ ~ i~GC.r , County,
~ Florida, permanently. cc'tr~
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` ~ (Name)
~ ~e~N A - ~o//:Ns
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; Uddress)
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~ Sworn to and subscribed before me thi~ day of
~
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,
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~ ~ A.D. 19 .
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- ~F!~blic Stste of Florida ~ae
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~ f.g,+,~~ ,.(To be e:ecuted in dupiicste and ori`inai filed with Ckrk Circuit Court, snd dupticate weth Tu As~essot)
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