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Deciaration of Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSt:SSOR,
~-t:~T--_ _ ('OUNTY, FLORII)A: 24Z
363
Ti~iti is my dc~lar;~tion of Domicil~ and Citizenship in the Stat~ of Florida that I am filing this day in
~ccor~lance, and in contormity with Section ?'?2.17, Florida Stahites.
1 was formerly a legal rrsident of _ ~ ' - ` l • and I
. `
- _ t~~~ ) (stace)
resided ~it _ ~ _ _ _ _ . However, I have changed my domicile to
Stre~t and Numbrt)
and am and huve been a bona fide resident of tlie State of Florida since day of `
- --~--~1-~----- - . 19_~~ and I residc at _ -~~t<~~,~5~~~•- ~ - ;
(Street and Numbet) {
- ~~`'='t ~ . -r.rc ~40 County. Florida,
(city)
and this statemeni is to be taken as my dcclaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Inse~i herr any pertinrnt facts, such as s~lr c~t propr~ty or businrss, ur relinquishmrnt of employment at tormer
domicile, removal of (amilY to new domicite, purchase of home, rtc.)
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fILEO AND RfC0ADf0
- ST.lUC1E CO!lNTY FLA.
ROGES a01TRAS
CIERK C1;:CUli COURT
RECOR!1 YEFIFIfO
Niw 21 91s RM'7Z
24
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I FURTHER CERTIFY that 1 will register at my local addnss when the registration books reopen, and °
comply with all other requirements of a legal resident of this State. {
1 FURTHER CERT that 1 have no intention to return to my fornier domicile, and I intend to remain in
- /~c.vc.C , ~ '
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~ Couniy,
Florida, ermanently. ~ ~
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S~(icx~iv~~twd'~utisciibed before me this a./_. _ ~lay of ~
, . .
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• Notary Public St~tr of FI a at Large ~ E~~ ~~f ~
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My Commission expires----_- 1~--
~To be e~ecuted in duplirate rnJ on~inal filyd ~~itfi C'lerk Circuit Coutt, and duplicate with Tax Assessor)
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