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Declaration of Domicife and Citizenship
TO THE STA AND COUNTY TAX ASSESSOR, ~~~6~
_ COUNTY, FLOR(DA:
This is my dcclaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in
accordance, and in conformity with Section 222.17, Florida Statutes.
1 was formerly a legal resident of - ~V ~'3 /i ~ Tv ~.v iV iI/• f' and I
(ciir) (stace)
resided at L~'Y~ vf y?~ ~t ~'S . Nowever, I have changed my domicite to
Streei artd Number)
and am and have been a bona fide resident of the State of Florida since 3~~. day of
, 19~ and 1 reside at - ~ _ ~ s"3S' ~y~~f'tfs ~e ~ D .
(Street andNumber)
~ fz1€~?c c„~ i~~ ft,~' ~r- ~'/E/1 e F, S T ~~i C i E County, Florida,
(ci~r) ~
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Inseri here any pertinent tacts, such as ssie of property or businas, ot relinquishmeot of employment at fortner
domicile, rcmoval ot fsmily to new domicile, purchase of home, ete.)
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fItEO AND RECORQt4
ST.1,UCtE COUIiTY FLA. ~
ROCER POItRAS
CIERx ClRCUIT COURT ~
RECORD YEP.IF~ED
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I FURTHER CERTIFY that I will register at my local address when the registration books reopen, and
comply with all other requirements of a legal resident of this State.
I FURTHER RTIFY that 1 have no intention to retutn to my former domicile, and 1 intend to remain in
~ , .~9~ , County, -
Florida, Qermanently. «"r~ ~
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Swd ,~'~~~ribed before me this day of
- ,~r -~~~~3~~ ~a~f~, 01 o mAy
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N y Pubtic State of tlorids at
My Commission expires - ~G ~ ,,Z'~
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(To be ezecuted in dupticate and originat fJed with Cltrk Circuit Court, snd duplicate with Taa~ Aasessor)
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