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23040'7 ~
Dec~aratior~ of Domicile and Citizenship ;
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TO THE STATE AND COUNTY TAX ASSESSOR, I
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Z v c~' ~ COUNTY, FLORIDA:
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This is my declaration of Domicile and Citizenship in the State of Florida that I am fiting this day ia ~
accordance, and in conformity with Section 222.17, Fiorida Statutes.
I was formerly a lega! resident of Ma r~'~- , C ed `r" 9~ q' and I
(City) (St.te)
resided at 39 ~ T~/c o T/ C i rc ~e N. tN . , However, I have changed my damicile to
(Sueet and Number)
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and am and have been a bona fide resident of the State of Florida since 3 day of
~a' , 19~Y and I reside at w• w• Fe r r~ S
/`~o r .s'-f-. ~ v c ~ e 5 ~ . L v ~ ~~e ~ ade~ ~a H~~~~
, County, Florida,
(c~ir)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in th~ State
of Florida.
(Insert hete any pertincnt facts, such as sale ot property o~ businas. or reliaquishment ot emplorment at former -
domic~e, removal ot familr to aew domiciie, purchase ot 6ome, etc.j
~6 lztt P v r c~ 4 s~t~ jl ~ 7~7 6?` e+'+~ G~~,.' 0~ e/er M~ y.~o v.
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~e 3~ c r•.. ~ e o.-9 S o/ d S// 9/ y v. E~ r 1 s.~ K'i` ? v~a ~•J
~OC~~-s~ ~s cer-~ iti ~o. ~~d ri a R~i r~ ~/3'~/7y'
f tE0 AMD REC4ROE~
S~. RO ERCPO
?R S
ClERK CiRCUI? CO
RECORO VERI~l60
~ ~ ~0 20 ~'~Z
z3o4o~ ~
I FURTHER CERTIFY that I will register at my local address when the registration books reopen, and
comply with all other requ"uements 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
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S'~• C , e _ -s , County,
Flo~,~ ~e3Kn~nently. cc~~y~
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, ~ = - ~ _ ~ 'yo n/ F.Qrri s
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• . ~ . (Address)
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S~i~vr~ ~,~r~,~Lbscribed before me this ~ day of
' • . . . ::i.~t.
u A.n. ~ 9 ~ z- -
'i Nowy Pubiic State of Fbriaa at Lu6e 0~~~ A~
~ My Commission expires
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~ (To be e:ecuted in duplicate and ori6insl tded with Clerk Circuit Court, and duplicate with Tu Asxssoe)
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g~OK~~i PACE24~ AGfl"Fc:rm ?l 22
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