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Declaratian of Domicile and Gitizenship
I~U Tf~l_ STATt: ANU ('OUN7'Y TAX ASS.:SSOlt, 24893~1
..-~y~~ _ COUNTY, FLORIDA:
Thix iti my drrlaratiun ot~ Uomirilr an~i Citizrnship in the Statr ot~ Florida that I am liling this day in
a~ror~{;?ncr, and in ronformity with Section 17. Florida Statutcs.
1~v;~s fonnc rl~~ a l~g.~! resident ot~ _.~3~,e~<.~l~ - C and l
• - _ . 1~--
(CitY) - (stalr)
r~si~tcd at ~~C~ -~~i~
_f~~i-~-___-_---_`--_- . Howcv~r. I havc changcd niy domicile to
_ trert a"nd 1Vumbrr)
a?~d am a~~d havr L~rn a bona f~?e residrnt of the State uf Florida sinc~ day of
~~j4r1 r_1..--- - . 19__~-~, and 1 r~sid~ :it /~~~_~_Z~ _ .CL___~~--f~___--
' Irret ~t(d humber)
~ _
~`y~"--- - • - County, Florida,
tCity)
~:nd this statement is to be tak~n as my dcclaration of citizenship, actual legai residence and domicile in the State
ut~ Florid:t.
(Insr~i hrrr any prrtinrnt fxtc, such u salr uf proprrl~ ur Dusinrss, or rrlinyuisAment ot rmployment at tormrr
JumicJa, rrmuval uf fam~l~ to nr~c domicilr, purchasr of homr, rtc.)
~ i~ ~a ~ N ~ 12 v~S1` _
i1~E0 ahC ~fCuaDEO
_ ST.IUCiE ~OJNTY F~A.
it~:.F~ =:+IiR~S ~
CLERK ~ ;~~~IT COURT
RFC~?Qr, V'::i=:~p
M~t 5 9 ss RM'73
248931
I FURTHER CEkTIFY th.:: l witi r~~~ist~r at my loral adefress ivhen the reeistratior~ books revpen, and
romply ~vith al1 other req!~irem~rits ot ~ le~al reside~~t ot~ this State_
1 FUR7HE CE:RTIFY that 1 hare no inte~~tion to return to my forn~er domi ~ile, and t intend to mmain in
~ ,
- - Cuunty-
F-loriila. permanently_ ~c•~'• i
- - ~o~r,v~d g. ThRos ~J
` J l,,i'• .CO , ~~~"1 a'-~~'_ „~I ~ -
J ~ • • -
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,~'JJ.i'••~'CJ,~ . . (Vame)
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l % °---3---- ~`"~~l~~fi _ _ _ .
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SK'iTr~ ~~uti~ribrd befors sne this _`~"~da~• of
~
~~1'1,L.~-`-,` - - - - - A_ D. I
•ROGfR PO e
- Notary uAlE~te of Elori 1 Lrr¢e -
~ .
~ty Commission expires----__ _ _ _ -
(Tu tx r~rcutrd in dupl~c~Ir rr.J ~~riF~nrl fdrJ «ith C'Irrk Cirru~i CourL anJ Jupliratr Kith Tac Assrsxx)
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