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Declaration of Domicile and Citizenship
TO TtfE STAT = nU CUUNTY 1'AX ASSk:SSOR, '
__~c-e _ _ _ CUUNTY, FLORIUA:
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'Il~is i. my ~icclaration ui~ Domicilr and Citiui~ship in thc Statc of
Florida that I am filing this day in
accardanc~, and in conforniity with Sertioii ?'?.17, Ftorida Statutt•s.
1 was formerly a ler:~! rrsident ot' __~~~q%r_-- - -•---~lG~ . and I
'TiL cc~~~~? ~ ~e-?i.e - (s~a~e)
rrsided :~t __f1~ __~Gl~[~.._,~~~_ G ~Howc;ver, 1 have changed my domicile to
(Strret and Numbrr) - ~
~nd am and have bren a bona fide rrsidrnt of the State of Flotida si ce ,;y=~c-r~a,-- day of
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- Ue h~ --~~~tt-__ . 19_. and i residr at - ~~_S~ ~rJl~Lu!
~ ~?J~~ (St~ret a Number)
~ yt~-t?<~ ~.~~d~--t~~Ttif,~ - • G'~-r _ County, Florida,
cc:~c.~)
a~~d this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Insrn hrrr any prrtinrnt facts, such as ~Ir ot pruprrtp or Ausinru, ur relinquishmenl of empbyment at former
domicilr, remo~al u[ family to nra- dumicilr, purchasr of home, rlc.)
~t~~(/(~
fiLEO a~D RECOR f0
SL ~pCi£ COUNty
ROCEn P~I;RAS
C1ERX ~a~~U~T COURT ~
RECORD VFPi~icp~_
~ o o I ~ o~ ~ 9 0~ AH ~
- ~ 7t
. 24303~
I FURTHER CERT[FY that t will register at my Iocal address when the registration books reo~en, and
comply with ail other requirements af a legat r~sident of this State.
1 FURTHER CERT Y that 1 have no inte ~on to return to my fornier damici , and I intend to r~main in
_ - ~ - / - .
, - - r ~~Gv_c-~_. _ _ Gc,~ County,
Florida, permane~itly. ~c~"• ~ '
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(Name)
~a- y~?r ~ e ~v Ne
- -
(Address)
Sworn to and subscribed before me this day of
C'~~'---~~~~-;~'~'-• - - A. D. 19_ ~
~ ....,-'~J~~s'~/-~ ~~L~'S~~_--
~ otary Publ& 84aCt of FloriJ•r at Largc
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My ~or~ni ~ves.~. - ~
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~y ~1e~Uted~in duplicate anJ ori~inal filyd with Clerk C"vcvA Court, aod duplicate with Tax Assessot)
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