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Declaration of Domicile and Citizenship
"('O THf: TATE: ND COUNTY TAX ASSESSOR.
. 245603
~ _ CUUNTY, FLORIDA: ~
Tl~is is my declaration of Domicilr and Citizenship in the State of Florida that l am tiling this day in
acror~iancc, and in coniormity with Section _'„_.17, Florida Statutes.
I was fornicrly a legsl residcnt of S c_~E^!~~ ._N'E W o~'e _ ai~~ 1
(CitYI (State)
~ O~ QR ~4a a W/~v G /~v However, 1 have chan ed my domicil~ to
r~sided at _ -------_-X g
(Strrrt and Numbrr) ~ ~
and am and have bren a bona fide rrsidcnt ot' the State of Florida since _ ~ day of
AGM ~1/E • `
fe~~c¢ 19_7 and I resicir at ~ 3
(Street and Number)
~ ~27' ~t.c~ • - T G / ~,c County. Florida,
(City )
and this statemcnt is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Insen here any petlinrnt facts, such as sale of pruprrty or businrss, or relinyuishment of employment at former
domicile, remo~at c~f family to nrw domicile, purchast ot home, ~tc.)
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F11E0 ANQ RECOROEe
fT.l11GE C011ATr FIA, ~
- CtEP.~Ctl;CUIT COURT ~C
• RfCOR~ ycR~f~EO
it ~ 4o eH'13 -
E
? 245~03
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4 1 FURTHER CERT(FY that I will rr,~i~ter at my local addr~ss when the registration books rcoE~en, ai~d
~ ~omply with all other requirements of a lc::il rrsi~lent of this State_
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~ I FURTHER CERTIFY that I hav~ nc~ inter.tion to return to my fornicr domicile, und 1 intend to remain i?i
. ~ ~ ~
~ oR7 /-~E~c.c~ - ~ ------'---~c.E-----------• c~o~:»t~. ~
~ i~lorida. permanently. ~e~"`~ _
/ , ~LiKe~.?.--0 ~ ~
~C=~~--~- - _ _
`(N,ame)
_ ~~.N:~t~:rr~a~~~ ~CL~ V 1 L~-- A ND
~ Sr _
= • • .
~ - .y
« - . _ - - - -
G; ~ - - -IAddrrss)
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~ -,~vi~r~,to.and s~bs~zibed beforc mr thi, ~3a)' of
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' ~ A.U. 19
:R? . :
. .....•••',1
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piuy Public Stale i~f Florida at ~zr
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yr-"~,. ? D t'RGi
J bflD1? ~.~?~7
. hty Commrssion expires l -L-
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(Tu be rxrcutrJ in duplicatr anJ uriginel fi~cd ~vith ('Irrk ('ireuit l'ourt. and dupli:atr with Taz Assessor)
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