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Deciaration of Domicile and Citizenship
"I'U THE STAT~ ND COUNTY TAX ASSk.SSOR,
~D 24'7655
, ~ _ COUNTY, FLORIDA:
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Tl~is is my d~cl~ration oti Domicile and Citizenship in the Statc of Ftorid~ that 1 am filing this day in ;
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accordancc, and in contorn~ity with Scction `'~'_.17, Florida Statutes. i
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1 was formerly a I:a:.~l r••~ ent of f~_ - ' and 1
(Citr) ( atr>
resided :~t ~~However, I have changed my domicile ta ;
(Strent and Numbrr) p ~
and :~m and have bren a bona tidc nnsidcnt ot~ the State of Florida since ~ 7 _ day of p
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- - - - . 19_~•Z. . and 1 rrside at _ 3 .3 ~__~u~'~~~...t~~~-~
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(Street and Number) ~
- • - G~..._~ COUiI[)/, FIOfI(~~,
(City)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Inseri here any pertinent facts, wch as sale of proprrty or businrss, or relinyuishmeat of employment at former
domicile, removal of family to ne~v dnmicile, purchasr of home, etc.)
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1.£0 4MG ftF~ ROfO '
~~lE POtTRA~s ~ s
~IER~ ~I~ClIfT COU~tT ~
RECURO YERlf1~a~~ ;
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~ 1 FURTHER CERTIFY that 1 wil! re,~ister at my local address when the rcgistration books reo~en, and
~ romply with all othrr requirements of a lcgal rrsident of this State.
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~ t FURTHER CERTIFY th:~t l ha~~~ no inter.tion to return to my former d~micile, and ( intend to remain in
~ ~ ~,~LP~i~~l. _ - - - ----~~--~2u ('ount~~.
~ Florida, permancntly. ~~~'`y ~
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;3 - - (Name) - . -
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. . O~iN ~C~hf.N~ .1N. • ;
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JSwo (~'arid sa6~r~ed before me this _ ~ay of
p~r ~ -
~ 'y`, /-~"..~~Q-= - - - _ _ , A. U. 19 l
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_ . ~ . . ~ ~E - - -(1`
• ''~Iota PuAlic State uf Flnnda at Largc
~ My Commission expires_ ~_--l~v - - ~~~K ~~u FAGt 2
(Tu t~ ~a~cuted in Jupli:atr end uri~:~nrl tilyd ~~iih ['Ierk ('ircuit Court. and dupli.ale ~rith Taa Assessor)
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