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Declaration of Domicile and Citizenship
TU TN ~ STAT ~ NU COUNTY TAX ASSI:SSOR.
_ _ ` CUUNTY, FLORIDA:
Tl~is i. my drelaratiun of Domicilc a~~a c~~~7~~~,n~~ in the State af Florida that 1 am titing this day in
arcordan~c;, ,~nd in ronformity with Sertion ???.17, Florida Statutcs.
~ I was tormerly a le~;~l resideni of .~~~t N_~'_1~~l~fL-_------_-------~- ~ . r -_-_i---- and !
(ci~r) (sta~e)
r~sidcd at ~~___~tst_ . Howcver. 1 havc changed my domicile to
(Strrct and Numbrr)
~nd am and have br~n a bona fide msident af the State of Florida since day of
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. 19 and i r~sid~ at _~r.4~
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~Sireet and Number)
~Q-~'r--- / ~1'- ~ . -_~~_~~c~.~ County, Florida,
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:~nd this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(insrn here am• prrtin~nt iacts, suih u sale c~f properly ot businrss, ~u rciinyuishment ot empioymrnt at fotmet
domicite, rrmocai of family to nr~c domicile, purrhrse r~f home, rtc.)
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- fN.EO AItQ RECaROE~
it uiC~f ~~~I~Ir Fl~,
iIUG£R POtTA~S L
~ , CLERR Ct3CU1T COURT ~
RfCORP YE~i~FlED...~....~.~
~AN ~ 9 43 aM'~3
2~4"19`~
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i 1 FURTHER CERTiFY that I~t~itl re~,ister at my loral address wh~r1 the registration books reo}~en, anc~
compiy with att other requirements ot' a lrg~l reside~it ot~ it~is State.
` 1 FURTHER CER7'IFY that I ha~~c no intention t~ rcturn to my forn~rr domicile, and 1 intcnd to remain in
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2o rn~sutRcribed hriorr me thi. day c~t~
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~ ~ty Cammission expirc, ~ - _
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(Tu hr r~rruteJ in du~,li.~lr and nrigin~l f~lyd ~~ith l'Irrk ("ircuit Courl, and duplicate wrth Tax Assessorl
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