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Declaration of Domicile and Citizenship
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TU~TH ~ STAT ' AND COUNTY TAX ASSESSOR,
,
_ _ CUUNTY, FLORlDA:
Tl~is is my derlaration of Domicile and Citi-r.enship in th~~ State of Florida that 1 am filing this day in
:1CC01' i1111'l'. .t~iti iii Vvii~v~uni NriU~ 1'll
~'~'-°"°'y S~ction _ .l , Florida Statutes.
.
l was fbnnerly a legaf resident of -~1~!------------ l~ !
i~---- and l
(CitY) (State?
r~sided at _.!?~~S L•~ ___s T However, 1 have changed my domicile to
(Strret and Numbtt)
:~~~d am ~nd have lx~cn a bona fide rcsidrnt of the State of Florida since _ day of
- . 19_~~, and ! resid~ at __~Q~_~1v-_ -2 Sr' -
- - ~ - - - --1=
j ~ (Street and Numtrer)
L d~~
- ~ county, Florida,
a~---- ~c~~r~
and this statement is to be taken as my dec~aration of citizenship, actual legal residence and domicile in the St~te
oi' Florida.
(losrri hrrr any prrtinrnt facts, such as sale nt proprrty or basinrss, or relinyuishmrnt ot employmrnt at tormer
domicile, rrmoval uf family to new domicile, purchasr ot homr, rtcJ
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' ~ FILEO ANO RECOROEO
ST.lUC1E COUNTr flA.
ROCER POITAAS L
CIERK CIRCUIT COURT
RECORO VER~~tEO
Ju~ i t 2 03 PH'?3
245488
1 FURTHER CERTIFY that 1 will rc~istrr at my lo~al address whrr~ the registration books reopen, and
romply with all other requirements of a legal resident of this Statc.
1 FURTHi?R .RT(FY that 1 l~av~ no intrntiorz to return to my forn~er do ~cile, and I intend to rrmain in
1 f
~ _ ~
_ _ _ - - - - ~ ~~OUTIIy,
Florida, permanc ntly.
- - - - - - - - -
` ~ ~ ~ ~ l ~G~ me
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- - - -
. . ~y (AdJnss~
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~ ancf•stt~jscssibed before ntr thi, ~iay c~f
' . .
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.,;i~ _ _ _ A. D. 19
_ •ro ; ~
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~,.13 :'~ublic State uf F7~ir'rda at la
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hty" ~.omm~ssitin expirrs -l ~
(To be r~rcutrd en duplic:ur anJ un~i~ial (ilyd with l'Irrf~ Circu~t C'uurt, and duplicate with Ta~ Assessur)
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