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Declaration of Domicile and Citizenship
"('U THE; STATE AND ('OUNTY TAX ASSt:SSOR, 245~83
_~G'-~_ _ _ _ CUUNTY, FLORIDA:
Tl~is is my d~claration ot' Domicile and Citizenship in the State of Florida that ( am filing this day in
ac~~rdan~:r, and in conl~orn~ity with Section ?„_.17, Florida Statutrs.
I was fornierly a lrgal rrsident of _ L!
E~/5~~i9(~~ , --~~_w_ !e~_ and 1
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3 / ~'~~T~/~ ~ ? y . How~ver, [ have chang~d my domicile to
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(Street and Numbrr)
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:~nd am and have be~n a bon~ fidr resident of the State of Florida since day of
S~p . 19_ and I resid~ at _l ~ 7 ~ _ ~/L
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lSireet and Numbrr)
~~7~ ,~i~iE~CL- ST~ ~c,=C iC
- - - - _ _ _ . County, Florida,
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and this statement is to be taken as my declaration of ~itizenship, actual legal residence and domicile in the State
ot~ Florida.
(InsrN hrrr any pert~nrn! tacls, such as s:fir ui pruprriy ur iru.iua~, ot retic~aaut;m:~t af r:a~lo;^:.r.t at [ermer
dumicile, temo~al uf f~mily to nr~~• dom~cilr, purchase of homr, etc.)
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I~URTHER CERTIF~' that 1 will rc~~ister at my lo~al address whcn the registration baoks reopen, and
romply ~~~ith all other requirements of a le,~~l msident of this State_
1 FURTHER CERTTFY ihat 1 ha~~e nc~ int~ntion to r~turn to my t~orn~~r domicile, and I intend to remain in
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_ - _ _ - - - - - Countv. ;
Florida, prrmanently. - ic~~Y? -
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(Name) -
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.:~1ys~or~t ~~t1t~~'clib~d hcfore mc this ~ ~ day of
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--,r~-`- ~ - - - _ A.D. 19~
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Nut y Publir $tate of Flurida a! LatRv'
~ ~~R~, 209 25~1 :
~i~~ (omn~is~ion e~pire~_ _ ~ ~ lC~~~~' :
(Tu be r~rcWrJ in duplicate and ,~nein.d f~led ~~ith ('Irrk ('ircuit ('~iurt, and duplicale aith Tax Asseuut)
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