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Declaration of Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, 24?~r18Q ~
~ _ COUNTY, FLORIDA: ~
t
This is m declaration of Domicile and Citizenshi ~
y p in the State of Florida that I am filing this day in
acco~dance, and in conformity with Section 222.17, Florida Statutes.
1 was farmerly a legal resident of , - _ and !
~j~~AX..C~ ~iy) ue)
nsided at _~~P ~ aM d~) . However, I have changed my domicile to
(Street and Number)
and am and have been a bona fide resident of the State of Florida since ~Cf ~2-- day of
, 19 ~-Z- , ~rid I residc at ~~f ~1 ~ - ~e ~ E' S
~~J _ 1 ~ , ~ ~ (Street and Alumber)
~ Ow1 -o ~ G~--~ COltrit)/, FIORdB,
(Cityj .
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida. ~
(Inser~ here any pertinent facts, such as ssle of property or businrss, or relinquishment of employment at formtr
domicile, removsl ot family to new domicile, purchue ot home, etc.)
.
. ,
~
Ff~'D Alt~ REC4Rif0
iT. LUGF ~flitll'~Y FIA.
~E COURT
RECOR~ VER:FtEr~
~s S !0 47 AM'~3
~4~180
I FURTHER CERTIFY that I 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 FURTHER CERTI Y that I have no intention to return to my former domicile, and 1 intend to remain in
! - ' - c.~-!y/ ' i~2~-~ir-s-~:~ , CountY,
I~ s,,': (city) ~
~Oj'1~ ~~P.Ilt~y. 1
1 ~ r~ ,
; s
: ,r , .9'~~
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. _
: i. ,;'~y,S...tl. (Name
, _{A,~U~" ~,T~<. ~ca~ /io1~'
. ~
. S ~t _
-'`O•;~ «<9t ' ~ (Address)
.<'F' .....y•' 1L`
~
~"'~~lA~'~liscribed before me this day of
- A.D.19~~
i N y Public State of florida at Laree O~ n~o ~CE2~01
dO~X i~
My Commission expires ~
(7o be exetuted io duplicate and onFinal f~led with Clerk Circuit Court, and duplicate with Ta: As.ussot)
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