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Declaration of Domicile and Citizenship
TO THE STA E ANU ('OUNTY TAX ASSESSOR> 24SO8S
_ ~!~~c _ COUNTY, FLORIDA: ~
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Tl~is is my decluratian ot~ Domicile and Citit.enship in the State of Florida that I am filing this day in
accordancc, and in contorn~ity with Sectian ?~2.17, Florida Statutes.
I was formerl a Ir ~a rrsident oi~ ~~L~11'_ •---`-~!~-2~-~~--- and 1
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(Cily?~ (Scatt) ,
residrd at .~1~ _.~1. --_~~~A• . However. [ have changed my domicile to
trret and Number) .
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and am and havr beeii a bona fide nsident of the State of Florida since ' day of {
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1a~~--- . 19 and I reside at ~~~1~~~~'-~~~'
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~ (Street,~snd N~t~Fr)
_ ' ' County, Florida,
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a~~d this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Insrri herr any prrtinrnt facts, such as sale of property or businrss, or relinyuishment of employmrnt at former
dumicile, rrmoval ut (amily to new domicile, purchase of home, rtc.)
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p~ ~ Ci?~( ~.~G~' t/~ 1
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f'!L£' JtND Rf C0~#~
sT.1l1C1E COU~fY Fi,,~ ~
ROCER POtT~AS
~LERR CiRCUIT COURT
~ECOao v£a~~ifo_~
` .Mr 1 il es ~'~3
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` ~ 245085
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~ 1 FURTHER CERTIFY that I will register at my loral address when the registration books reopen, and
~ comply with ail other requirements of a Irgal resi~lent of ihis State.
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~ 1, RTHER ~RT1F that 1 have na intention to return to my fornier domicile, and l intend to remain in
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y ~ - -~~~Gl'c'~/ - - • - ~ - - _f.t~-------- - - • (~ounty.
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- ~,SVVprn ~Aanc~t~s6r~bed belor~ m~ this clay of
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~ . ~ - - - _ _ A.D. 19 ! ~ .
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utary Public State uf Iluri et LarFe U~ f' ~
600M ~U~ PAGE ~~6~
.:y
~ty Commission expires _ _ _-l~_'-7
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~ (To he e~rculyd in duplicate anJ ~~n~;in,d f~lyd ~~~th ('lerl. ('ircuit C~~urt, and dupli::~te ~~ith Tax A~sessot)
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