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Dectaration of Domicite and Citizenship
"I'U THE STAT ~ ANU COUNTY TAX ASSESSOR, 24~i~,O3
.
_ COUNTY, FLORIDA:
This is my drelaration ot' Domicile and Citiz~nship in the Statc of Florida that 1 am filing this day in
accorciancr, and in conformity with Sertion 222.17, Florida S• utes.
[ was formrriy a Irgal rrsidcnt of _ and 1
r~~~(CitY) . (State)
r~sid~d a~ o~~-.,~-f -~f=~-_ , . Howevcr, I have changed my domicile to
(Slree nd ivumber)
and am and have bren a bona fide resident of the State oi~ _Florida since day of
• 19_~.2-. and 1 reside at 1~0 ~7 ~
p n ~C (Slreet~aod Numbet)
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Couniy, Florida,
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and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Ftorida.
(Inseri here any pertinrnt facts, such as salr ot property or businrss, or rrlinquishment of employment at fotmer
domicile, temoval ot family to new domicile, purchase of home, ete.)
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1 FURTHER CERTIFY that 1 will register at my local address when the registration books reopen, and
comply with all other requirements of a legal resident of this State.
' i F„ ,RTr~F~t-CF,~RTIFY tha have no intentio» to reti~ri~ to my former domicile, and 1 intend to remain in
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F~Of~~; ~CTII13T1t:~~j . (CitY)
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Sworn to and subscribed before me this day of
v " _ -9~%~~
- A.D. 19~_ .
` ~.C~S~!`-
ta~y Pu ic $tate vf Florida a rge ~
My Commission expires~`~~ p R `
600h ~~o ~'~Ct
(Tu br raecuted in duplicatr and uriKinal filyd with ('lerk Circuit Coutl, and duplicate with Taz As,tessot)
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