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Declaration of Domicile and Citiz~nship
TO TNE STA ' ANU COUNTY TAX ASSESSOR,
24565 5
,
~ ~ _ _ _ COUNTY, FLORIDA:
This is my dcclaration of Domicilc and Citizcnship in the Statc of Ftorida that 1 am filing this day in
accordance, and in conformity with Section "22.17, Florida Statutes.
I was formerly a legal resident of AN ~D G! ~L , 1~~/ /110 / S and I
~ (citr ) (stste)
resided at ~ a~___~ -~E C~ 5~T . However, I have changed my domicile to
(St~eet snd Number)
and am and have been a bona fide rc:sident of the State of Florida since ~ 7~~ day of
--~~1a1i~~-- . 19 and 1 reside at __t Q~ ~ A R ~ E h3 f 1~ ~ U~_
(Street aad Number)
_ Fo aT P_~ Q r c e.. _ ,_~S'. u ~ i,~. CouniY, Florida,
cc~~Y>
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Insett here any prrtinrnl facts, such as sale of property or business, or telinquishment of employment at former
domicile, remo~al of family to neav domicile, putchase of home, etc.)
w
Q~c.«c~ia~~ Gl~-~ c~ 8 ~ .
.
fuEV ~~a nECOROE~
iT. WC1E C01fNTY FLA.
CLER~C ACi~jtTRC0i1RT
'ECC+R~ VERt-1E0...,~, ~ '
I~ 10 06 AM'73
~ 245655
t FURTHER CERTIFY that t will r~gister at my local address when the registration books reopen, and
comply with all other requirements of' a legal msident of this State.
I FURTHER CERTIFY that 1 have r~o intention to return to my former domicile, and 1 intend to remain in
/ O (~1' ~ I e t~ C ~ _ _ • S. T 1.3 u C 1 ~ _ , County.
Florida. permanenily. C~'J~ O~~ 7-y,CLe
_ ~'~~PO ~ _.~-~f~_~~~t~!t-~ - -
(Name)
Q3 ~ .
. . ..r _1_ ~ ~sfi C~9~ D ~ Auc;
_
- -
, (.~aa~ess>
~ : . . •
. ; • ,
~wtiF~ aft~cti6scribed bef~re me this __fS_ Jay of
. , `~i: ~ $ A. D. 1
_ - --T---
` i
' • ;o• : i~ 1~~~
~ ~ -r~ -
o Public State of Plurid at Lsr¢e Q R ~
"~~~:'~,•~'.~'t` . ~ aooK 209 ~nci ~91
hiy Commission cxpires--- T~-_--
(To be r~rcuted in duplicatr anJ uriFin~l filed w~ith Clrrk Circuit Court, and duplicate with Tax Assecsor)