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Declara~EOn of Domicile and Citizenst~~p
'i'O Tllt: STATt: Ai~'U COUNTY TAX ASSESSOR. 25'~91s
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S_,r .C G C ~.E, COUNTY, FLORIDA: ~
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7'I~is is my drelaration of Domicile and Citizcnship in thc Statc of Fiorida that 1 am Cling this day in
accordancc, and in conl'ormity with S~ction 2~2.17, Florida Statutes.
i was formerly a legal resident of ~1 +~f- ~ , and I
(c~ir) (sate)
resided at y~ ~v U 2 7f~ S~ , However, I have changed my damicile to
(St~eet and Number) s`
and am and havc been a bona ~de resident of the State of Florida since day of
S
U
L-T , 19 ^1 and I reside at ~ 7~o f~ D~2 E s 7,¢ Jj
~Street aed Number)
, sj .C U C?,~ County, Florida,
(c~ty) -
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(lnsert here any pertin~nt facts, such as sale of property or business, or relinquishment of employment at tormer
domic~7e, removal ot family to new domicite, purchase of hame, etc.j
Applying for homestead
Entering children in school : ? .
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fLLEO 1~NU REG~ ~
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CER PO~T~t~ ~
CLE~~ C~~
ifD ~DtFR~
RF_COP.P VE
~ $ 2D AN'~3
25'7916
. ~ $
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; I FURTtiER CERTIFY that I will register at my local address when the registration books reopen, and
g comply with a1t other requirements of a legal resident of this State.
3
_ [ F THER CER IFY tha have no intention to return to my former domicile, and I intend to remain in
s
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- S T v~ i E , County,
Florida,.perm~nei~}t~.,, cc~cr~ '~u.u.~c,.v~~
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_ _ ~ v - A , ~P - ~ (Name)
; - ~ ;^~a= - ~ ~7G ~~o,C'~sTi9-
~ ~ - . ~ •~J r ,~v;~ (Addteu)
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= Sworn te., ti~iitia~ptb~d:before mc this day of ~
~ ...ist~?t~ . i r
j ~ .D.19~~' ~
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; ROGER POITRAS, CLERK CIRCUI COURT
' II F. c~~':'C,
_ y D~C R~C~ c~ C•1•~~.,