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Declarat~on of Domic~le and Citiiensh~p
I'U TtIE STATt~ NU ('OUNTY TAX ASSt:SSOR,
`~„~:%l , - -L''t'Q _ CUUNTY. 1~ LORIUA:
Tl~is is my drrlaration ot~ Domicilc and Citirrnship in the State of Florida that l~m liling this day in
ac~or~l~nce, and in confarmity with Scction ~~?.17, Florid:~ Statut~s.
1 was tormerly a Icgal resident qi~ = _ - • - --L c-``~- - and l
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r~sidrel at!L- "t_ s-Y~'T-%r.C~=`=~-=-~C~--~-c-c:L:_~ r_ Now~ver, 1 have changed my domicile to
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and_ am and hav~ brrn a bona fide resident of the St:ttc of l~lorida since day of ~
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~i:-~-1~_-_ : `-C _/,v_~, :itl(~ 1 rl'11(1~ :1[ ~~_s ~~P--L
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~y L- - - ---a a
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_ _1~.~_~c-s~-- - . ~-~~---r:-.~~i~rc..~~ Ccunty, Florida,
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:~nd this statcment is to be takrn as my drelaration of citizenship, actua! legal residence and domicile in the State
ui~ Florida.
(Insrr~ hrrc any prrtinrnt facts, such as salr oi proprrty or Ausinres, or rrlinyuishment oi rmployment at furmrr
dumicilr, rrmo~al of family to ne~~ domicilr, purchasr of home, rtc.)
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~ I FURTHER CERTIFY that 1 will rr~~ister at my loral addr~ss ~~~hen the rrgistration books reopen, and
~ rom{~ly with ~ll othrr requirements of a lezal r~sident of this State.
~ t FURTHER C[:RTIFY that 1 ha~~e no int~ntion to return to my fornier domicile, and 1 intend to remain in
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`_~~tcG~ - - - _ _ - - - - ~~,-~_u-~~~- 'ounty.
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~ '~-c_~_~y ~~i~l,t~ . A. D. 19>'
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Notary ~c Stat uf FlunJa at L-rrKc
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11y Commission expires _ ~il-~- _ f ~-./Il J -
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~ (Tu bY rxeculed in duplicatr anJ ~~ri~inal filed ~cuh ('Irrk Circud CuutL and Jupttcate w~~th Tax Assesux)
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~ BOOK 2~9 ~4t.f 1~c17
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