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25~928
Dectara~ion o~ Do~~icile ar~d Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
~ ,G ~ •
~'~z.?~-G COUNTY, FLORiDA: ~ ~
This is my deciaration of Domicile and Citi7enship in the State of Florida that I am Cling this day in
accordance, and in conformity with Section 222.1 T, Florida Statutes.
1 was formerly a legat resident of ATL.AA7TA eS F b~2 1~4 and I
(Citr) (Siate) ;
resided at~0 •~'~X +~.~J~,~?Q~9~gELCD9It) ~D rvJ . However, I have changed my domicile to
(Street and Number)
and am and have been a bona fide resident of the State of Florida sinc~e day of
u~N ~ , 19~., and I reside at Sl a3
(Sueet aad Number)
~~u2T ST L G l e- , ~''T' C. v C,1 ~ County, Florida,
(City)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida. -
(Insert here anr pertinent facts, such as sale of property or business, or relinquishment ot employmeat at former
domicile. temoval of family to new domicJe. purchase of home. etc.)
Applying for homestead
Entering children in school :
~ ESTA~LISJa IQ6S~I)~?JG~C' lN FL021tD~ ~a1~R Ta 1'f'1~ '1'Y1JL?-~'"~O~r
b2. ~`r1 I~C- N1 ~ ~J"j'^ -
FILED AH~ RECJRDED -
ST. IUCI~ COl1NTY FLA. ~
ROC~~ A~tTAJ~S ~
~IERK~ C~::;,UtT COURt
RECQR~ Vi tFD
,ku~ 15 I 4s PM'73
256928
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~
1 FURTNER CERTIFY that I will register at my local address when the registration books reopen, and
comply with all other requirements of a legal resident of this State. f
;
~ I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
~ Pd~' S} ZC~C) F , ST L. U C/~. , County,
E Florida, permanently. ~~"y~ ~4'.c ex ~3 e~ K0.r- d,~r.
~
~ , :
• ~ ~•r
~ p, U ~ T ; , (Name)
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~ : s~u't•i'''••. oG%?`°~.'.
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~ RI ' ~ ~ ~ On~P T ~ , ~ (Add~
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=~:S o arnfi3ub~jFi~ed betorc me this ~ day of
,
. ~ ~ ' ` .
~ ~ V
G~ A. D. 19~
i~~~ tt„ O `e,~
_
~ ,
~ R ER POITRAS, CLERK CIRCUIT COURT
~ By D,c bo~r2~5 PACt1~'S3
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