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~ec~aration of Domicite and Cit~zenship
"fU Ttil: STA1~t: \D C'OUNTY TAX ASSl.:SSOR, 248810
.~uC_ CUUNTY, FLORIUA_
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Tl~i: is my circlar.ct~un ot' Domicilc antt Citiz~n,hip in the Statr of Elorida that 1 am filing this day in
a~carJancc, and iii conlbrmity with Sertion '"__'.17. Floridu Statui~s.
1 was t~orn~crly a Icg;~) nsident ut -~L~ - . . . !L ~__LI~ • and 1
ICitYI (Slale)
r~,idrd :~t _ ~3 U_~~
=~r- - - Howrvrr, ! have changed my domicile tQ
. (Strert and Numtrrr)
a~:d am and havr brrn a bc~n:~ 4idc r~sidcnt oC the State uf Florida since day o!
~ J~%~-~Gz`'
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(Street and Numbrr)
--~c~r ~---~~e~-c ~ . --S°~.~. u, ~ , ~ - county. F.orida,
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::nd ::.is statement is ro br tak~n as my declaration of citizenship, actual legal residence and domic;le in the State
uf Florida. ~
(los~ti here arty ptrtinen! fxts, such u salr ~~f ptuprrty or businrss, cx relinyuishmrot of rmplo~mcnt at tormer
domicilr, rcmu~al ot family to nrw dumicilr, purchasr of home, rtcJ
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1 FURTHER CERTIFY that 1 will rc~,istrr :~t my local address ~vhcn the registration books reopen, and
com~ly with all othcr req~iirements ot~ a legal resident of this Siatr.
1 FU4THER ~RTIFY that I h~ve no intention to rcturn to my~ fom~~r dcmicile, and t intrnd to remain in
` --..--~CCd - ` ~ounty.
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~ ' S:~~q~y~ anQ,~t~ribed before me this day oi
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( To br rxtcut d in dupi~cate and ~~nK~nal f~led N~ith :'lerk Cercuil Court. and Juplicatr wilh Tax ~lssessor)
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