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Declaration af Domic~le and Citizenship
~4940~
'TO TNE STAT ~ NU COUNTY TAX ASSESSOR,
~C~~ _ - ~~<<___ COUNTY, F~ORlDA:
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This is my declaration ~f Uomicile and Citir.enship in the State of Florida ihat t am filing this day in
acc:ordancc, and in conforn~ity with Section 2~~.17, Florida Statutc~s.
I was formerly a ltgal n;sidcnt Qf _~,e~~!~ _~_~4' t~~_ and !
j ~Q ( S f~ S' (CitY) (State)
msided at . How~.~ver. ! have changed my domicil~ to
(Strret and Numbrr)
and am and have tx~;~ a bona ~dc resident oi' the State of Florida since 7s1~-~ day of
_ 19_~~, and 1 residc,~ at ~~d ~ Y~-; L-,/t/l ~ L~~ .
(Street and Numbet) }
.
_ ~ ` _ _~~C1~ - _~~-t County, Fiorida, {
(c~cr)
•~nd thic statement is to be taicen as my declaration of citizenship, acti~al lega! residence and domicile in the State
of Florida. ~
' (lnsen here any prrtinant facts, such u satr of ptoperty or business, or telinyuichmenl of employment at formet
dorrticile, removal ~~f family to ne~v domicile, purchase of home, rtc_)
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FILE~ A!10 RECORDEO
SL LUCI~ COUNTr FlA_
ROCER FOiTRAS t
CIfRK C!.°.CU1T COURT ~
RFCOlt~ VER'rtr~ r
I~ s1 10 zi AH'T3
249408 ?
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1 FURTHER CERTIFY that I will register at my_lo~:~l address When the rcgistration books reopen, and
comply with all other requirements of a legai resident of this State_
I FUR"FHER TIFY that i have no intention to retur~~ to my fonner domicile, and 1 intend to remain in
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' "t' ~ , County,
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• ~ (Name) ,
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~'~E.=.~:~~=~~~C~.;;~~~ ~°~--~ca.a~~aitl~eR~- ;
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S~brn~t~Ulid subscn~ed before me this ~_1!'_ day of
!y3! ~ A.D. 19_~...~-.
soc~s-~o~t~as~-c~~------- -
ar~e
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(To be executed in duplicate and onginal filyd a~ilh Clerk Circuit Court, and doplicate with Tax Assessor)
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