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Declaration of Domicile and Citizenship
"('O T E ST l: ANU ('OUNTY TAX ASSL:SSOR, 2450'7'7
_ ~ L~-L!1 CUUhTY, FLORIUA:
'This is my drrlaration ot~ I)omicile and Citiz~nship in th~ Statr ot Florida that l;~m filing this d~y in
accoraanrr, and in coni~c~rmity with Section 17. Florida Statutes.
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1 wa. !'orn~crly a Irg:~l rrsidrnt of ~~'_cz'~~L~~ .~.r?!jt~ltf~Q~~vand 1
(('ilY ) (Statr)
rrsided at ~~~~L4~_ . Howevrr, 1 have changed my domicile to
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sn •nn and havr b~rn a bona tid~ nsid~nt ot~ thc Statc of Florida since 4~_------ day ot
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-~:2?~--~__~!. . 19 an~1 I nsidr at ~ _ - Z~' -
Slrert and Number)
w- . _ _ - - - - - • - Count Florida,
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and this state~ncnt is to be .~hen as my dcrlaration of ritizenship, artual legal residence and domicite in the State
uf Florida.
(Insrr~ herr any prrtmrot lacts, wch as salr u( pruprrly or bu~inrss, or rrlinyuishment ~~f rmplo}•mrnt at formrr
domicilt, remo~al uf f~mily to nea~ dnmic~k. purch•rsr oi homr, rtr.)
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$ 2450'7'7
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~ 1 FURTHER CE:RT1Fl' tli.+t I will n~~istrr at m~~ Ie~~al a~idr~ss whrn the registration books reo}~en, and
~ com~~ly with all oth~r requiremenis ~f a 1<<~al r~si~ent of this State.
~ 1 FURTHER C:RTIFY that 1 ha~e nc? intenliun to return to my forn~er micile. and 1 intend to rcmain in
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~g Flori~a, permanrntly. ~c~~~•?
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=y :.3~gr~to•~.ke~b3t:ribed brf~~r~ m~ thi~ ~~iy of
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sr Nutary Public State uf nda at Lar~te ~OC~ z~9 {~GE~~~
`1y Commission rxpires ~ f ~ _
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(To hr r~rcuteJ in Jupl~c~tc ~nJ ~~n~m.+l fdrd ~~ith c'Irrk ('~rcuit ('~~urt, and dupticatr ~~ith Tax Asscssor)
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