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Deciaration of Domicile and Citizenship
245196
TO THE STA.~tiD ('OUNTY TA~C ASSk.SSOR,
.
_ COUNTY, FLURIUA:
This is my dreiaration ot~ Uomirilc and Citi-r.c•nship in the State of
Floricla th~t ! am filing this day in
.
accord;~nce, and in conformit~~ with Scction ~'?.17, Flo ' a Statut~s. ~
1 w~?s formerly a Icgal resident of ~'and 1
,~~r) • - (scatr ~
resid~d at ~C~------__ . However, I h~ve changed my domicile to
(Strert and lYumt+tr)
;
and am and have bcen a bona t3de nsidrnt of the State of Flotida since _ _ day ot i
- - , l 9-~ ~ . ~nd 1 resid~ at - ~ v ~ ~Q ~j~'
~ • - treet and Number)
~~~c~ County, Florida,
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and this statement is to be takcn as my derlaration of citizenship, act~~al legal residence and domicile in the State
of Florida.
(Insen hrre any pr~tinent factc, wch as sair of pruperty or businrss, or retinyuishment ot rmployment at furmer
domicile, rcmural ot family to nr~c domicile, purchasr of home, rtcJ
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/ Ltp ANO RE4 R
i~ ROCE
POiTIIA~s
QLERK CtRCU1T CQIIRt
RECORO VERtFIEO~~.~.
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z~ssss
1 FURTHER CERTIFY that ! will registrr at my local address whrn the registration books re~pen, and
~omply with all other rcquirem~nts of~.~ 1«al r~sid~nt of tiiis State_
1 FURTHER CE Y that I ha~•~ n~ intention ta return to my forn~er domiciic, and 1 intend to remain in
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Florida, pcrmanently. ~
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;~a;~r(Jt~~b~~~~:d h~l~~re m~ tiii: c)ay of
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Ndtary Pu ~c Statc ~~t Elonda at L:+rcr
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41y Commission expires _ ~ -l~ ~ SQOM ~0~7 ~'AGE
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(To I+e r~rcutaJ ~n du~l~. at. ~nd ur+~+n,~! (ilyd :~~ih ('irtk Cucuit fomt, rnd dupiw~ir ~~ith Tax Asussix)
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