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Decl~ra#E~n ofi Do~ :~cile and Citi~enship
TO TtIE STATC AND COUN1'Y 7'AX ASSI:SSOR,
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L v F' COUNTY,_FLORIUA:
This is my drelaration of Uomicilr and Citi•r.rnshi~ in thr. Statc of Florida that I am filing this day in
accordance, and in conformity with Section 222.17, Fiorida Stat~~tes.
1 was forniccly a legat residcnt of S c~ v i t-) ~,~l~ I Al ~ E L ~J /t/E w J f- rc .1 c+/ and 1
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, (citr) (stace)
resided ac 2?~ w~~ J PE 2,~~ r(-~ ~ I I~Z D . However, 1 have changed my domicite to
(Slreet a~d Number)
T
and am and have becn a bona fide residcnt of the State of rlorida since day of
v~~ , 19 and 1 reside at Z Z~ ~ ~/J ~c,,~¢ 2 ~0 2~.
(Sireet and Number)
~ P I~ rL c~ 1- ~ c' r County, Florida,
(c;~y~ '
and this statement is to be iaken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Inserl here any pertine~t tacts, such u salr of propcrty or business, or relinquishment of employment at fotmet
domicile; temoval of family to new domicile, purchase of home, etc.)
Applying for homestead C~ ~ ~ C~,
Entering children in school :
. F~~EO ayt~ .~FCORo
3T CUC?f CO{~Nty fE0
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i 1 FURTHER CERTIFY that I will register at my local address when the registration boohs reopen, and
_ comply with all other requirements of a legal resident of this State.
~ I FURTHER CERTIFY that 1 have no intention to return to my former domicile, and I intend to remain in
~ .
~ ~ I. P i F 2~' ~ ~ I. L t.~ c. ~ CountY,
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- Sw~oj •t~a~td;~~~5c~bcd bcforc n~c this day of
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, R~GEK POITRAS, CLERK CIRC IT COURT
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