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Deciaration of Domicite . ~nd Citizenship
~l'U'fHE STATy~,-,~ Nl)('OUNTY TAX ASSk:SSOR, 249516
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~ -t.e%~' u'{ - COUNTY. FLORIDA:
Tl~i~ is my drrlaration ul' Domicilr and Citizcn.hip in the Stat~~ uf Florida that f am tiiing this day in
arcur~ta!~~•r, ;+nd in contorniity with S~ction _'22.17, Florida Statutrs.
! ~s;;; i~onnerly a Irgal resident of - - ---r - - • ~ - and !
, `
tc~~,~~ ~s~~~r~
r~si~!cd at _~S___ ~~''~e--_~-•-•.-e~.- . However, 1 h~ve changed my domicilc to
~ (Str~1 ~nd riumber)
and am and have tx~n a bona lide resident ~oC the State of Florida since day ot~
~...L-•-'`J . 19_~_?- , and i reside at `~^~-6' ~^-N-~- _
' ' ~ (Strert and Numbrr) '
- • ~_--x.`"`."'c~ - County, Florida, ~
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and this statement is to be taken ~s my declaration of citize~~ship, artu~l legal residence and domicile in the State
c~f Florida.
(Insrri herr any prtlinrnt f~cts, such as salr oi prupnrty or businrss, or rrlinyuishment uf rmployment at former
domicile, ~emoval uf family to neN• domicilr, purcAasr ot home, rtc.y
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ST_IUCIE ;;O~NTY f~~.
ROC~F F4iTRAS ~
CIERK C~=CU~t COuni
REC)R~ vE~irtED_~ v !
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1 F(~RTHE:R CERTIFY that I will register at my local address ~vhrn the registration booi:s mopen, and
comply wiih all ~ther requirements of a legal resident of this State_
1 FURTHER ~ER'fl~Y tfjat ! hav~ no ir~tcnlion to return to my t~orn~er domicile, and 1 intend w remain_ in ~
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r "'`^'w- ~^-'c...-c-,-- - - . County.
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Flori~ia crmanet~~ly. ~c~'`=`~- -
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Srdv_cc~~~•to.• ~5~~~`ribed before me thi~ day of
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- - A.D. 19
Roa~t ~o~Tw~s, c~t
- - - - -
~,o~~ D..w . :R~ 211 P~~f ~469
, ~ ~ occ!
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(To tre rarcuted in duplica anJ ~rriRinal filr wilh ('Icrk ('~rcuet Courf. and duplicate with Tu Assessot)
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