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Declaration of Domicile and Citizenshi g'~~
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~U !'tit: STATE AND CUUNTY TAX ASSk:SSOR,
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- - ('OUN1'Y, f~LORIDA:
1 i~i. ~s my drelaration ol' Domicilr and Citizenship in the Statc ot~ Florida that 1 am tiling this day in
:~::uniancr, and in coniormity with Sc~rtion ,?,.17. Florida Statutrs.
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I was iormerly a egal resident of ----1----- and l '
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t~~~~~~~1 _d'? . However, 1 have change m domicile t :
(Strert ~nJ Number) ~
:~n~i ~ m and havr bcrn ~i bona fid~ rrsident of ihe State of Florida since day ot~ ~
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1 . ~ ~i! ;,~~a , «~~a~ ~c ~ ~ 3 S_ ~ - - ~
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.,~1 this statement is to br taken as my declaration otY citizenship, actual legal residence and domicile in the State
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(Insrr. hrrr any prrtinrnt facts, such as s:+lr of property cx businrss, or rrli~yuishment of rmployment at tormet
dumicile, remc~val oi family to ne~v Jumicile, purchase of homr, rtcJ
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t LEO ANO RECOROE(! .
S~.lUC1E COUNT~Y FLA.
ROCER POiTRAS
C~EP,R CIRCUIT COURT
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1 FURTHER CERTIFY that I will r~gister at my local address when the. registration books reopen, and
;:~~;~iE~l~~ with all other requirements of a legal resident of this Statr.
1 f~URTHER CERTIFY that 1 havr ~~ntention to rrturn to my fonner domicile, and 1 intend to remain in
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' ~-t- County.
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~'?~~tt~':4.~~~1'~s R~dttly. (c~~~>)
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4~,..~~riz tn~~nd subscribed before mr this da~' of
/ ~~c t~ -Q~ A. D. 19~~.
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~`~._,~u~' or,G~~-
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" ry Public State Flurida at Lar~c
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(To br r~rcutrJ in Juplicasr anJ ori~;inal f~lyd ~+ith ('Irrk Circuil Court, anJ Juplicatc Nith Tax Assessor)
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ecoK 204 Fnct z25~ -
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