HomeMy WebLinkAbout2016 Declaration of Domicile and Citizenship
l~~! 1 tt~ STA : AN D(:OUNTY TAX ASSL~:SSOR, 234261
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-ccct!_ _ ('UUNTY, FLOR11)A:
Ct?i, is my ~lrclaration ot' Domiciir ,~izd Citiz~~nship in th~ State of Florida that I am filing tliis day in
.~~~ur~iai~~r. an~l in ronformily with Srction "'.17. Florida Statutrs.
1 u•as lorm~rh- a i~~:~i ~~S~a~~~c o~~ -~AN J"v~9.t/ ~ L/~Td 1~/C O snd I
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(~'~~Y 1 lStalr)
rr,i~i«i ;~t ~ 7 ~R~~i- - r~_~~ -~~~h--- . Howcver. 1 h~ve changed my domicile to
(Strrrt and Numbrr)
,~n~l am and hav~ hren a bona tide residcnt of the Stat~ of Hlorida sincr _ d:~y ot'
~~y 19 7_Z, and 1 r~sidr at 2_~~___ ~!~A/!~/~
LI.ST.
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/ . , (Slreet and Number)
p 7 . -
6~?T l _ /1_C'L _ - - - • - - S/ ~ UG County, Florida,
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:,~i tiii~ statem~nt is to bc tak~n as my derl:~ration of citizenship, artual Irgal rrsidence and domicile in the State
.,t [~i~~rida.
(Insrr~ hrrr any prrtinrnt facls, such as s:ilr uf pruprrty or husiness, or relinyuishment of rmplo~ment at formrr
dumicile, remo~al uf famih• lo ne~v Jumic~lr, purehace of home, rtc.)
Tv~O ~i~~~C'L
r,~~,ti- ~ ~~~vi~L~.
fILED ANO RECOR [p
Sr. ROC RC
OuTRA ~u ~G
CLERK CIRCUIT COUAT ~
~ RECGRD VERtf~ED.,~
~ tB 3 e7 PH'lt
~i ~34261
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I~~l!RTHER CERTIF=Y th:~t I will m~ister at my loral address w~h~n th~ mgistration books reo~en, and
.:~,r,}~1~~ with ~Il other requirements of a I~g~l residrnt of this State.
1 t=l1RTHER CERTIFY that 1 ha~~e no inter~ion to rcturn to my fonner domicile, and t intend to remain in
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~~~~r ~CC ~eL' ~'T ~ cJciC . c~~~~,cy.
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: ;;~rr~i.t. E~,~rman~ntly_
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~ (Name)
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~ 2 ?6 /tiSA/t S T ~
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~ ~aa«ul
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~ ~i qr~sd cli
•..,r~~ t~~ artd suhs~[itxcLb'1~ ttte tlti~°2 ~1~~~ of
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~ PIi~ _~uble~ State o[ F]orida at La -
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`•I ~ ('ommissioli t~pires-~ ~ _ . -
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(To br c~rcuteJ in Juplicalr •rnd uri~inal filyd ~tiith ('Irrk Circuit Court, and Juplicatr wi~h Tax Asscssor)
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a~204 ~2015 . -
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