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Deciaration of Dornicile and Citize~nship
2~414
TO THE STATE AND COUNTY TAX ASSESSOR,
_.r~- COUNTY, FLORIDA:
77iis is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this d3y in
acconlance, and in conformity with Section 222.17, Florida Statutes.
1 was formerly a legal resident of ~~.~G.._. ~~~~d. '?2u,,•~ 3~ Y
, and I
tcur) .ce)
resided at ~~~L~!~ • . However, I have changed my domicile to
(SUCet and Number)
and am and have been a bona fide resident of the State of Florida since ~J ~ day of
- , 19Za~, and I reside at ~ y7 ~.aR.c;C~ ~~T'
cstr«~ a~a Hwnee.)
~a*-~ , County, Florida,
y tc~~r~
~ and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(lnserT Aen any pertinent facts, such as sale ot ptopettr or businas. ot ~elinquishmcat ot emplormmt ai to~rmer
domicle. removal ot familr to new domic~7e. purchase of home. etcJ
~ ~ WCIE COW~~.1~~
CL RKCC RCW
~T.~QJ~ ~
~ RECORD V~RIP1Fp~~
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~ t,
~`~414
I FURTHER CERTIFY that I will register at my local address when the tegistration books reopen, and
~ comply with all other requirements of a legal resident of this State.
~
! I FURTNER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
~ P~ ~ County
• , ,
Florida, permanently. cc~'r~
'~'~r.a .
;
(Ataaae)
~ y7 .a..~,~. ~ _
~~d~~,
Sworn and subscribed before me this
~ da of
Y
~ -
i _ A. D. 19
E
~ 'c State oi Florida at
: . . ,
` - . -
• a.
: m~
~ j ~
t ~ ~itJ' : xy -
r
r l Y~~. ~
~ ~ ~ Kexecuted in duplicate and ori6ipl f8ed with Ckrk Citcuit Court, and du hcate with Tax As~asor)
1'.;~kt v .
.
~~,~~~.1 ~y\,~
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' ~ ~ aooK~OZ PacE245~
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AGO Furm ?i-22