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Dec~aration of Domi~~t~ ~nd ~i#izenship
2492~4
7'U TH = STAT ~ AirlU ('OUNTY TAX ASS~:SSOR,
.
, - ~ !%~_F' _ COUNTY. FLORIUA:
Thi~ is my d~~claration ot~ Uomicilc and Citizrnship in the Statr of Florida that i:~m fli~lg this d:~y in
arror~lancr, and in ronformity witi~ Section ~'?.17, Ftorid,i Statietcs.
! was tornierly a legal msident oi~ and I
~c~~y? l (sw~e~
R~ided a1 _~.+~4~ --~Q~~tu~- . Howevcr. I have changed my domicile to
(Strrrt anu Numbrr)
and am and have becn a bona fde resident of the State oi' Florida since _.!3-'~-~-~ day of
• 19__7~_, and 1 reside a[ •J'/o/ _~ZD~. 4~--~.~m~~~4~_.iiX/~<«cP ,
- - -r~-F=S.~C4- Streel and Number)
(~(~C _ - ~~.tl~.J~J--- ~
. __~~~~J County. Florida,
cc~~>•~
.:nd this statement is to be t:~ken as my derlaration of citizenship, actual legal residence and domicile in the State
~~t' Florida.
(Insrri here any pettinrnt facts, such as s:slr o( pruprrty ~x business, ur relinyuishmeot ot rmpto)•mrnt at former
domecilr, trmoval of family to nrw Jomicilr. purrhasr of hnme, rtc.1
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ROCc "n r JITit~IS ~
CIERK Ci.',CUt7 ~p~pt
RECORC Y~f'~r#Es~
I~t 1 ~2 ~ P!~ '13
249204
1 FURTH~.R CERTI~=Y th:~t ! will re~ister at my loral ae:clress w•hrn ihe reg;stration books reopen, and
~um~ily with all other req~~irements of a ie~~a) risident of this Siate.
l FURTHER CERTtFl' that t havc no intrntion to return to my former domicile, and I intend to remain in
r,~ .
0`~ V ~c~e.t.cft~ ' '
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~=lorida, ptrmanently.
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~ ~•.F~` , ^ (Address)
15ti { s . ~
.i~•, y~~` .
~'•S~~~ ~ribed befor~ me this day of
-~E:,~~~' - - A.D. 19
ROGfJi POfTRAS„ l~et~
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(Tt? br e:rcuteJ ~n dupi~rrte anJ on~;~nal filyd ~cith Clrrk Circuit Court, and duplicate wilh Tas Assessor)
aG~!!~~~ PItC?~,V~~7
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