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Deciaration of Domicile and Citizenship
TO TH~ STAT ~ ANU ('OUNTY TAX ASSk:SSOR, 24'74~2
.
. _ _ ~u~ _ _ CUUNTY, FLORII)A:
Tl~is is my declaration af Domicilr and Citir~nship in the Statc of Florid:~ th~t t am filing this day in
accordancr, an~i in ~anforinity with Section '~'.17, Florida Statutcs.
i was fornierly a legal resident oi~ . _ . ~ _ - , - and 1
(CitY) (state)
rrsidrd :~t v?C'~- ~___~i . However, 1 have changed my domicile to
(Street and Numbrr) ~
and am and havr be~n a bona fidc r~sident of thc Statr ~f Fiorida since ,~s'1~_~~ day of
. 19_ L_~. ~nd 1 reside ai _~~/7 S_~ 1?...rt~.~um 4 Q~ -
reet and N~iber)
~'-~~-G~ - ~~s~--------- . - -~_s^Sa.'~-=-~-~~' COllilly. Florida,
cc•~~y)
and this statement is to be tahen ~s my deciaration of ritizenship, actual legal residence and domicile in the State
ol~ Flarida.
(lnsrn hete any prrtinrnt facts, such as ~Ir uf proprtty ot businrss, or rttinyuishment of rmployment at fotmrr
domicele, remo~al of family ~o nevr dumicilr, purchase of home, etc.)
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~../L~1^~! GL,(iv.~ C--~[~C .
ST~LUC E COUNTY FLA.
ROGER ?81TRA5 `
CIERK CtRCU1T COURT
RECOF~J VEF.IFIED
FEe 8 10 s6 AH'73
24'~4~?2
i FURTHER CERTIFY that 1 will register at r~~y local addmss when the registration books reopen, and
romply with a11 other reqt~erements of legal resident of this Statc_
1 FURTHER CERTIFY that I ha~~e no intention to return to my forn~er domirile, and 1 intend to remain in
~ ~ ~
~ -c G-c.~_ _ .
"~,~1 , - - - • ~---~~~'~l-~-_ , County.
Florida, permanently. <<~'"~
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liu.a e j~"GeNf i
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`C„~ , I - ----~nad~eu~~----- -
_ ~ : :
::~~~,yv~orri~faa~d,snbS~ibed befe~re me this ~ay ot~
.
l~'~~ ~',r` _ U. I N~~~ .
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1~ (~y
~l~ ~
~~J~~/• • v.~,l .--J-i -L_~~_ 1l_.? C._ . _
ofary Public Slate ui Ftor~t Lar~r
~ty Commission expires _ ~ l ~ _
~To t~ rcrcutrJ ~n Juplicatr anJ ~~riiinal f~ted «i1h ('terk Crrcuit Cuurt. and duplicate x~th Tax Assessor)
R~oK2~.0 P~~E249? ,
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