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Declaration of Domicile and Ci~izenship
TO THh STA'T ~ AND CUUNTY TAX ASSL:SSOR, 249316
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_ ~c~~~~-.! . . _ COUNTY, FLORIDA:
Ti~is is my dcclaration of Domicilc and Citizrnship in thc Statc of Florida that i am Cling chis day in ~
arcor~anrr, and in eoni'ormity with Sc~tion 2?2. ! 7, Ftorida Statutcs. ,
! w~s formcrly a legal resident of ~ n11~d,d • and 1
~ } lc~~r> csa~~~
nsidrd at __,~7_~~~~.K:[~2.1u~~-~-1~~ Noweve~, 1 have changed my domicil~ to
(Street and Numb:~)
and am aiid have b~~n a bona fidc.• rrsident of thc State of Ftorida since dav of
---~1~Gt~~4-~- • 19 and ! residc at _~Z~• y ~i^L ~Q.G '
, ' (Strtet and Number)
-------~Z---L~s.c<<c~ . _ County. Florida,
(c~ty) -
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Insrrl here any ~tinrnt facts, such as sale oi proprrty or businrss, or relin~uishment of rmpioyment at fotmer
domicJe, remo~al of family to nrw domicile, purchase of home, rtc.)
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~E~ nNG ~ECOKDEO ~
ST_ ttlC(t COUNTT FLA.
~ lt0~~.~ : ,i~~RAS
CtFRK ~t-:;,J;T ~OURT
NE~QF.i. 7~ r;f~r~
M~ 9 la 4i A~! '73
249316
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~ 1 FURTHER CERTIFY that I will re~ister at my loral address when the registration books reopen, and
E comply with ali other requiremcnts of a legal resident of this State.
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! 1 FURTHER CERTIFY that 1 have no intcntio~~ lo return to my former do "cile, and 1 intcnd to remain in
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; - -tGC-C- , County,
{ Florid~,lje~''{.`
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Sworq~t nc~jtb?3cribed before mc this day of
•..~~~rr.,
/`_-~i"-'`~-t~'G'~ - A.D. i 9~~
~ RQGER POITRAS, Cierk
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(To Ifr eatcuted in duplicate d uriKinai fited with ('ierk Circuit Court, .nd Juplicatt xith Tax Assessor) ~
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