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Declaration of Domicile and Citizenship
"t0 THE STATE ANU COUNTY TAX ASSESSOR, ~t~50$8 ,
~ ('OUNTY, f=LORl1)A:
Tt~ii is my de~laration of Domicile and Citizenship in the State ot' Florida that I am tiling this day in
accor~lancr, and in contormity with Section ~"__'.17, Florida Statut~s.
1 was formerly a legal rrsident of __-----_--~.Q~~~~---- and I
((:ilY 1 (Statr)
r~sided at - Howevcr, 1 have changed my domicile to
(Strect aod Numbrr) .
and am and have txen a bona fide resident of the State of Florida since ____-.~~~L- day of
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-/j~-- i~ , 19_ ~ and t reside at T+~ (v T
(Strret and Number) ~ ~
- --~t~Z~ - County. Florida,
- (Cit> )
:ind this statement is to be taken as my declaration of citizenship, acttial legai residence and domicile in the State
of Florida.
(Inser: here any ~tinrnt facts, such u sale of property or businru, or relinyuishment oi employment at formrr
domicJe, removal of family to oe~.• domicile, purc~asr ut home, rteJ
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~ I FURTHER CERTIFY that 1 will rc~ister at m~• lorai a~idress wh~n the registration boaks reopen, and _
~ comply with all other requirements of a legal r~sid~nt ot this Statr.
1 FURTHER CERTtFY that 1 ha~•e no int~ntion to r.:turn to my fornier domicilc, and 1 intcnd to rcmain in
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c Flori~a. permancntly. :
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9 Nu ublic Statr ut 1 lur at LarKe O R 209 ~pE
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~1y Conin~is~sion erpires _
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ITu f~ r~rcutrd in dun[:.~tr ~nd uri}m~l filyd ~c~th (1rrA ('~rcuit C~~urt, and Jupli:ate ~vith Tac ~.ssexsor)
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