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Deciaration of Domicile and Citizenship
~ 245092
TU Tt{t~ STATL ANU ('OUNTI' TAX ASSl:SSUR,
~
• __~-c~..- COUNTY. FLORIUA:
Tl~i. is my ~lcrlaration ot~ Domicilr ;~nd Citiz~nship in thr Stat~ ot~ Florida thst 1 ant flling this day in
accoraa~?rr, and in cont~ormity with Section I FIOfI(I~ SI:1tUIt5.
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t was farn~erly a (egal nsidrnt ot~ ~ ~y_c--T ~c • .
~ _ _ - ~nd 1
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q ' 1 ~Jiyirj
T~Sldtd :l~ ~ d/!_- ¢ a'~ci~, • T~ _ Howe~~er, [ have changed my domicile to
(5trrrt and Number) - -J - •
and :~m and havc br~n a bona fide residrnt of thr State ot~ Florida since day of
_ _ - - . 1 _ 1 and I nside at 1 7_O y ~'n-i Q~, -
- - -
. ' (Strert and Number)
_
~t `--c-,-'t,- - • Couniy. Florida,
ICity>
:u~d t~is statement is to bc takc~~~ as my dcclar:~tion of citizenship, actual l~gal residence and domicile in the State
ut Florida.
(Insrr~ hrr~ eny prrtinent facts, surh ~:fk uf ptuprrty or bus~nrss, or relinyuishmrnt of rmploymrnt at formrr
domicilr, rrmo.~al ut famil>~ to nr~~ Jomirilr. purchase of hume, rtr.)
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i•J-,~G~ ~~7?~r~ L~'~~G~`~ LQ~%Gf
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t~iv°cif coa
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- aocf~ po~r~~s 1,
c~fa+c c:: ~wi couaT
REeaRa vFatf~Fo
•~r e ~r si AN ~73
245092
I FURTHER CERTIFY that I will r~tist~r at m~~ loral address ~~-hen thr registration hooks reo}~en, and
~ont~~ly v?itit all othcr rcquir~m~nts ~~f a Ic_~al r~si~icnt of this Statr.
l FURTHf:R CERT(FY that 1 h.~~~c r~c~ i~~tenti~~n te~ return tu m~ former nti~ilc, ~nd 1 intend to rrmain in
7 ~
~S..-c~2-~, _ • - - ' - -~=G~-----
~ - - co??nty.
Florida. p~rmanrntly. - _
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I:~~ ~~0~.~ l'•'~'~+~ L~.J._.~ . _
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_ ~ ; ~i . . ` _ (Addrrsa)
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~'Swont-tci:~i~ ~fbs~ibcd bel~ore m~ this ~ c1:,y of
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` • ~ - - - . A. U. 19
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Nutary F'ublic Sta~r uf Ilun t Larer
~
~ty Commission exrir~s ~ / ~ _
(T~~ bc r~rcutrd ~n dupG:a~c ~nJ nn~inal LIrJ ~+uh ('Irrl~ ('irruit Court. and dupliiatr Nilh Ta~ Assessor)
e~oM 2U9 ~c,E 2~ I~
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