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- Deciaration of Domicile and Citiienship ;
TU THE STATC ND ('OUN"TY TAX ASSESSOR, 248295
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_ t-~-'~ __COUNTY, FLORIDA:
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This is my dcrla~ation ot~ Uonticilr and Citizenship in the Stat~~ ot~ Florida that [ am Cli~zg this day in
~cc~rdancr, and in contorn~ity with Scrtion 2?2.17, Florida Statutcs.
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I was formerly a leg:il rrsidet~t ot' ~~u~/- and 1
lc~~r) (su~e)
f
rcsided at - : . Howcver, f have changed my domicile to '
(Strert and Numbrt) i
S
and am and have bern a bo~~a f~de residcnt of the State c.~l' Florida since day ot ;
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- - . 19 _ _ _ ~and 1 reside at _ O_cP' __~D
„f~ , , ( and Numbe~)
- '=-.:t=~_~ - • County, Florida,
(City )
and this statemrnt is to be taken as my declaration of ~itizenship, actual legal resiclence anci domicile in the State
of Florida.
(Inxn h~c an~ prrtinrnl facts, such u salr of propr.ty or business, ur relinquishmrnt ot rmployment at former I
Qomicila, i rmovx: of family to nc~v dom~cJe, purchax ut homr, rtc.) ~
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I FURTHER CERT[FY that 1~viil register at my local address wt~en the re~istration books reo{~~n, and `s
comply with a[I other requirements of a le~;~l resid~~nt of this State. `
1 FURTHER CERTI hat 1 havr no intention to return to my forn~er domicile, and I intend to rrmain in ~
, :
c~~ County,
, _ - - - ~t~~~~=- / =
Florida. permanently. ~ - e ~I e. i S e y
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- ~ `~.'i.~'~~' - - - ~Name~- -
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~ = - - - - (Addrris?
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t~ r~'~u~ ~ scribed befure nte this d~+y of
A_D. 1y_~-~ -
RpGER PptTRAS, Cierk
s~
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(To be rxecuted in duplk•rte and ori~;in~l fileJ ..ith Clerk (•"vcuif ('oort. and dupiicate with Tax Assessor)
_ sonK 211 ~acE 75g , , . . , - ; . .
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