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Declaration of Domicile and Citizenship
TO TNE STATE AND COUNTY TAX ASSt~SSOR. 245323
-~!I~; 27--'--~~~-~----COUNTY. FLORII)A: ~
Thi~ is my drelaration of Uomicile and Citizenship in thc Statc of Florida that I am filing this day in
accordanc~, and in conformity with Section ?~?.17, Florida St~tutes.
I was formerly a legal resident of ,-_-~0 0 f~~>P~' .~ct / and t
So I (Ci Y) 4 (51ate)
r~sided at ~~r~- _~1~%~~~ , However, 1 have char.ged my domicile to
(Strtet and Num r
:~nd am and have lx~n a bona fide r~~sident of the State of Florida since ay of
----,0?3 , 19_~e3 , and 1 resid~ at 3•~D C' - oj) L~~JC' .
(Stteet and Numbet)
-~-1-C~~C~---_ - o~.
~~e ~ i P County, Florida,
(c~~Y)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicite in the State
of Florida. ~
(Inseri hrre any prrtinrnt facts, such as sale of property or business, or relinyuithment ot employment at formrr
domicile, removal of tamily to nrsv domicile, purchase of home, rte.)
~
~a~ ~obe~`r ~oro«~
~i m ~a u~~e ~c ~ oro~c ~'1 ~
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!)obin {zq~ ~ ?~~c p e~out'l
1
~ o~~,~ a r r ~ o b o 1 e~.c, ~ k i
f1Lf D AM ~ Rf COR11Eo
ft. WClE CODUfTr fy, t~~
R4GER POITMS t
CLERK CIRCUIT ~p~T~
RfCORD YFR~FlfO_..,._~jL
.~N ~ 29 ~'~3
24Ei323
I FURTHER CERTIFY that t wilt rc~~ister 3t my lo~al address when the registratio~~ books reo~en, and
comply with atl other requiremea~ts of a Ie~al reside~~t of this State.
1 FURTHER CERTIFY tl~at I have no intention to rcturn to my fornier domicilc, and 1 intrnd to rcmain in
~E . j.u C ? ~ County.
' P C - - - - _ ~
Florida, perntanently. ~c•"~ ? . - - - • - - ~ - 5 o b o~T e ..u s k
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`~,~~~t~tur~,~.,~ [!~~~n
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. -ri; -a~q~• (Name
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i- _ . .~7' (Addressl -
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b~nd sut~cribcd before mr thi, clay of
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~ ` - . - 4. D. 19 ~ .
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~_~t,~";iici+~`' ' G t ~ ;
- - _ - -
ota~y ublic St.~te of Ilurida at L.arce ~~O ~rr
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i~1y Commission e~pires_ ~ ' l~ - _ - - ~
ITu be r~rcuteJ in dupliratc anJ ~.riEin.d (ilcd ~ith t'lerk ('ircuit Court. anJ duplicate ~a-ith Tax Assessor)
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