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Dectaration of Domicile and Citizenship
TO THt: STATf: ANU COUNTY TAX ASSt=.SSOR,
~~~ct-c_-~-~- ~~~~itv,~'y ~I (~R il)A:
71~i; is my dc~rlaralion ot~ Domicile and Citizz nship in the St.~te of Florid~ that 1 am tiling this day in
accordanrr, and in conformity with Sertion i 7, Florida Stattrtrs.
1 was farmerly a le~?a! resident of _ G~L~.
- _ _ . - and 1
Ic~~~• ) (s~a~r?
~ i _ ~
. - _ _ _ _ _ - However. 1 h~ve changed my domicile to
(Sttret :~nd Numher)
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and at~ and ha~~e lx~n a bona iid~ r~sidrnt oi~ th~ Statc uf Florida since day ot'
~-~cw'~,.~ ~
- _ • ~ ~ ~,~,a < «,~a~ :,t _ ~f - ~ ~ - /5'~--
• (Street and Number)~ ~
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- _~a r~- ~-=t'GL-- - - • - ~--~c , Caunty. Florida,
(c'~ts)
and this statement is to be taken as m~r derlar:+tion o! citirenship, actual legal residence and domicile in the State
of Florida.
(lnsrr~ here -rny prttinrnt facts, such as s:wlr ~~r ~~~,rr«. busin~ss, or relinyuishment of empluymrnt at tormrr
domicile, trmova) uf famih' to nr~~- dc~mir~lr, putchase of home. rtc.)
S~_~~yT~.sY" ~2,1~G~ • l ~'tiu~
t~/' ` s
~J~'~`-~~' -~r~~
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G' - _
f1LED 4NJ RECBROED
ST_ lUC1E ~OISNTY F~A.
RQCER ~OtTRAS
C~ERlC Gt= CUIT COURT
a~CORO v£PIFIED
L
F~a 1 I si PH'73 G~c,
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1 FURTHE:R CERTIFY that I will rreister at my lor.ii address when the rcgistrztic~rz books rro~en. and
romply ~vith ail other requirem~nts of a ic~~~i resid~nt of ti~is Statr.
1~=URTHE:R CER~'!FY that 1 h.~~•~ nc~ intenti~~n tc~ r~turn to my t~ornirr domicilr, :lll~ 1 intend to remain in
~-t._~C.E'it-'~'~ ~C.c,~t~C,
- - - - - . _ _ _ _ • ('ount}'.
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Florid~:'prrni,anently ~c"` ~
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~ary Pohlic S~atr I InnJa at t ar~r
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~1~~ C'ommission rxpires _
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~Tu br c~rcutrd in du~hr:~~r .~nd ~rnFinal fil~•d ~~i~h (lrrk ('ircui~ Cuurt. and dupltcatr w~~h Tax ~sussor)
ioo~210 ~?c~2~~~
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