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Declaration of Domicile and Citizenship
TO THE STAT~ ANU COUNTY TAX ASSt:SSOR, 24`~'79'~
,..~~..,u-~~-? _ COUNTY, FLORIDA:
Tliis is my drelaration of Domicit~ and Citi7enship in the State of
Florida that I am Cling this day in
accor~lancc, and in conformity with Scrtion ~".17, Florida Statutes.
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1 was formerly a kgal resident nf _ _ _1~ _~~cu? , ~y~~-~~-c_ and i
~i,~i (city) ~ (s~atrl
residcd at ~~_~_5~~-_ 7______~'U~_•___..____ However, ! have changed my domicilr to
(Strert and Number)
and am and have bc~n a bona fide r~sidrnt of the State of Florida since c~~~~day of
1_! C1~ . 19 .`1~-- and i rrside 3t _ _.~-~~~t-rr'N,n ~~e~ ~ - -
~ _ , _ (Street and Number) l
-
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= - • County, Florid~,
(Citr)
and this statemeni is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Insrri here any prrtinrnt tacts, such as sale o( prupert~' or businrss, or relinyuishment of rmployment at formrr
domicile, rrmoval of family lo new domiril~, porrhasr of hc~me. ~tc.?
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~ ~ j /j S~. LtIClE 40l;NTY FLA.
V ROCc 07 i RAS
CIEP,x C+::CUIF COURT
Rf^.'1R^ V:='tFIE~
F~e I~ 9 ~9 AM'~3
24'7'79'7
1 FURTNER CERTIf=Y that [ will rc~~ist~r at my locat address ~c~hen thr rrgistration baoks reo~ert. an~t
comply with aIl other requirrm~nts of a i<<~al rz;icient of this State.
1 FURTHER CERTIFI'~that I l~avc nc~ intention to rrturn to my forn~er domicile. and 1 intend to r~main in
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Flqyeida:'xrr~qi~nently-, ~c""~
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T . • ~ ~ ~~~_41.l~ _ ~t '
- ,Q . : a r: Y : Z . ' (Name)
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,Swofi~~t~.~.~r~a~~8yel~bed beforr me thi; l~ ~1,~~~ of
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_ _ _ _ _ . A.~). ~ 3 .
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- 4__ lm 7?'?_~ _ s~c~.:
~ otary F'ublic Statr of F lorida lar~r
My Commission expires ~ ~ _ - ~pOK~+~o PACE~r~~
(To be rcrcuted in Jup6r,dr :~nJ ~~n~~n.d fil~•d ~c~th l'Ierk ('ircuit Court, and Juplicale Nith Taa Assessor)
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