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Dectaration of Domicile and Citizenshi ~
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TO THE STATE AI~lD COUNTY TAX ASSESSOR, ~
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~ _ COUNTY, FLORIDA: " '
This is my declar~tion of Domicile and Citizenship in the State of Florida that 1 am filing this day in
accordance, and in conformity with Section 222.17, Florida Statutes. ~
1 was formerly a legal resident of ~~-~~f
w ~-k~- r and I
(ej~r) ~si.ee~ ~
resided at ~ . However, I have changed my domicile to ~
(Street and Number) ~ ~
and am and have been a bona fide resident of the Statc of Florida since ~3 day of ~
- _ ~
- - , 19-r~ and I reside at `Q~ ~
(Street and Number) ,
_ . ,~~5-~-~ County, Florida,
(c~ir)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the Siate ;
of Florida. .
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(tnsert he~e anr pertinent tacts. such as ssle of pmperty or businas, or relinquishment of employment at torme~ ' E
domicile, removsl of fan~ily to new domicile, pu~chase of home, ete.) ~
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Applying for homestead
Entering~children in school : ? +
~a-+l•-t~-~ .~_~.~aa~-rv :
y~'~~`~"''`~!`' 'l "~`'"`4~"J FILEO ?MO RECORQED ~ :
S~. WCIE ~COUN?r flA. ~
~i_~~~ AOCER P41T8~S L S
~a~,.,~,~,~ CLERK GIRCUIT COURT ~
RECORO +f R~f ~f 0 ~
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2S7'734 ~
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I FURTHER CERTIFY that I will register ai my local address when the registration books reopen, and ;
comply with a!! other requirements of a legal resident of this State. ;
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I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in ~
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County, ,
Ftorida, permanentiy. «'`Y~ ' 3
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• (Name) ~
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SwoRrL~;and su6~cr~c~1 before me this-?~ day of
:t r;. ~ ~
- nl. i~. ~
A.D. 19~
. • ~ t •.W "
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ROGEK °'~~~'~A9•~'~~.CIERK CIRCUIT COURT ~
ny D. C - ' BOCK ~G.~~ PACE ~~~2 .
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