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Declaration of Domicile and Citizenship
7'O THE: STAT ~ ANU COUNTY TAX ASSE:SSOR,
COUNTY, F ~oR~~A: 246'711
Tl~is is my drelaratian of Domicile and Citizcnship i~~ thc Statr af Florida that 1 am filin~; this day in
accordance, and in conformity with Section ~??.17, Ftorida Statutes.
1 was fonnerly a(eg;~l resident oi ~a~~~------------- •_--~L'--'----___ ;~nd I
c~~~y ~si~~r~
r.:sidrel at __l
Z~_~__ ~Q ,~/~~~~L~~~ Howevzr, t have changcd my domicile to
(Street and Numbr?)
and am and have be~n a bon~ tide resident of the Staie af Florida since _~1-~~-3 day ot
. 19--- and I rrside at _ L2-~_- ~
, ~~~~treet and Number)
~ ~ ~ • ~ • County. Florida,
- -
(c~?>• )
and this statement is to be taken as my declaration ot~ citizenship, actual legal residence and domicile in the St:~te
of Florida.
(Insert here anp prrtinent facts, such as sale uf pruperty or Aa~irerss, or rrlinyuishment of employment at tormer
domicile, removal ot family to ne.v domicilr, purchase ot home, etc.)
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V ~ " i~ IUCiE cOUMrr FtA.
' ` ~ ROCER ~OtTRAS
CIERK Ct ,~~tT COURT ~
RECORp YERt=1E0~
_ ~ 1y 2 4i PH'~3
24~;~11
; 1 FURTHER CERTIFY that I will r~,~ister at m~~ ta~a! address when the registration books reopen. and
~omply with all other requirements of a le,•al r~sident ol~ this State.
` 1 FURTHER CERTIFY that 1 havc ne~ int~ ntioii to return to my forn~er domicile, and 1 intend to remain i~~
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Florida, perman~~tl~ ~ T~ ~v rv~~ N~-
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1-:'• : _ • _ ; _ ~J, . t! ~ J
- x ' i Z ' y - ~~~~~~~FEl~_ _ "
+ ' 'f'~%Av B Ir~~ j ~tt~ - (Address) L%~ "c'e-e-C
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~'s~,to.anJ3.~1~~cr~bed hrfare me thi, _ ~ clay of
.
f-~ „„4;~•~'~
` - - - - . D. 19
i - /%;'~lt ~ % (/~i~
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f , ~N~t Public State uf flori~a at t ar¢ - -
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: ~ ~ ~ = _ - ° R 210 ~ 1~29
My Commission exrires-_--_- - - ~ b00K
i
(To be executeJ in eluplicatr ~nJ ~rn~:~n.d f~lyd aith ('Irrk l'irtuit ('ourl, ~nJ Juplicatr wilh Tax Assessor)
_ - - - ~ - - .
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