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Declaration of Domici~e and Cititenship
"I'O THl: STAT ~ NU COUNTY TAX ASSESSOR, 245244
,I ~1_~- ~ COUNTY, FLORIDA:
Tl~is is my drelaration of D~micile and Citizertmhip in the State of Florida that t am ftling this day in
:~ccor~ancr, and in conformity w ith Section "2, i 7, Fl~rida Stati~tes.
1 was formerly a le~:al residr~~t of _~~~-_~~C/I/?/QiY~~vt, ---~~-~-7~~_ and l
(Cit>•) (state)
resided at _ ~Y_F _W _ ~a1y~C/_____.___ _ . Howcver, 1 have changed my domicil~ to ~
(Street and Numbrt)
and am and have be~n a bona tide residc.•nt of the State of Florida since ~ day of
_ - • } `1 at:d l r~sidz at _ __L_~~ ~ /~l,,~l~
(Street and Numbcr)
~~~.T _~l~~L'f • - S % L r- f~ County, Florida,
(c•~~. ~
and this statement is to be taken as my declaration of citizenship, artual legal residence and domicile in the State
of Florida.
{Insrr. here ~zy ~r!i.^.e~t f~cts, such as sale of proprrty or businrss, or rclinyuishment of employment at fotmer
dnmicilr, rrmo~al of family to neN• domicile, purchase of Aome, rtc.)
~~/U/ ~ ~ So~~/
~/~%~Y/C/~y E~ ~~~lf,~ if1 " ~ .
/~/'l ~Y ~/~iY~ 7' /~ii//~ y" ~ ~ ~8c'~iE" co s
O~EF pfl~~~ ~
-C.L~R1( C1FC~1tT ~ .,~1
~RECORD VER+~t~,~~4~
- ~w ~ 4 ~ ~#1'13
245244
1 FURTHER CERTIF'Y ti~at 1 wili rcgister at my lorat address wh~n thc registration books reopen, ~nd
comply with all other requircments of a legal resident of this St~te.
1 FURTHER CERTIFY that I h;~~~e no intrntion to return to m}• fonner domicile, and 1 intend to remain in
~
,
! _-~~ly~f/f'~~_ _ • _ ~e~------ C'ounty.
~ Florida, pernianrntly_ - (r~~•?
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='3wAZn Toa s?~scribed bcfor~ z»e this ~ d:,y of
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~-''''1...-,r:.S~~ - - ~ - - - - - - - - -
~~ntary ublic State of FloriJa at Larg
~fy Commission e~pirrs - ! ~ 0 R
eoo~ 209 r~ci ~94
(T~~ hr r~rcutrd in dupli.atr ~nd ~~nhinal filed «i1h t'Irrk Cirru~l Cuurt. and duplicatr vc~th Taa As.uswr)
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