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Declaration of Domicile and Citizenship
1 c) THt: STATE ANU ('UUNTY TAX ASSESSOR, ~1~2
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~r `v ~_Le' COUNTY, FLORIDA:
Titii~ is my declaration of Domicile and Citizenship in thr State of Florida that 1 am filing this day in
a~~~x~iancr, and in cont~orn~ity with Scction ??'.17, Florida Statutcs. !
I was t'ormcrly a Irgal rcsident of
__SY-'-~p~!%~~~=~.~--- .~1 A~~~~ d and 1
lc~~r) (sa~e~
r~,i~ircl at ~ T - - ~ _ 3 ~ . Howcver, 1 have changed my domicile to .
(Strrrt anJ Numher) N QI
;u~~i am and have been a bona t~de nsid~nt of the State ot~ Florida since day of
~v iv - . 19 2-_. and 1 reside at ~ ~ ~
~'Y- _~_-°..sd _.__~V .
, (Strret and Number)
t
j 'P i e~ ~ e_ S j_-1
c ~ e _ County. Florida,
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i ;;~~i this statement is to be taken as my derlaration of~ ritirenship, actual legal residence and domicile in the State r
uf Florida. R
(lnsrn here any prrtinrnt facts, such as salr af pruperty or businrss. ur rclinyuishment of empluyment at former
domicile, trmovai ui family to new Jumicilr, purchase ot hume, rtcJ ~ 1/ y / p~~ ~ ~
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i FURTHER CERTIFY that I will rc~ister at my loral address when thr registration books reopen, and
:u~»F~ly with all other requirements ot~ a Irgal resident of this State.
I t~l'RTHER CERTIFY th~t 1 have nc~ intention to return to my torn~er domicile, and 1 intend to mmain in
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~ }~l„ri~ia. ~~rmas~rntly. `!/i //i.~/j1 Q•!l/S c c :
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(Name)
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(Address)
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c~rn t~, :~nd sub~;t]~b~i before me this ~ da~° of
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~ ''!/`,j~1~~~~l1i~?iai t;~uted m dupGralr and unKmrl fdrd w~ih ('Irrk ('~rcu~t Court. and duplwale with 7u As.usxx)
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