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_ 260219
E3ec~~r~~~~~1 iC~C~~~ECii~ ~C~t~ Ci~l~.~t~S~~i~
.
TO THE STATE ANU COUNTY TAX ASSI~SSOR, ;
o . ~ ~
_COUNTY;'FLOR(DA: ~ ~ ~
~
This is my declaratio~ of Domicile and Citi7e~iship in the State of Floricla that 1 am filing this day in ~
accordance, and in conformity with Section 222.17, Florida Statutes.
1 was formerly a legal resident of' ~"•J ~ and I ~
.
(ciir) (sc,ee) ;
resided at ~%?/1~ . However, I have changed my domicile to ~
i (Street and Number) ~h ;
and am and have been a bona fide resident of the State of Florida since day of ;
, 19~c~, and 1 reside at a
~ (Su t d Number)
. ~~-~-~-P County, Florida,
- .
tc~~r)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida. • -
(insert here any pertinent facts, such u sale of prope~ty or business, or relinquishment ot empioyment at former
domic~7e. removal ot family to new domicite~ purchase of home, ete.)
Applying for ho~r~estead . . .
~ Entering children in school : ~
a /I'.% ~i~'~-- ,
. L~/~2~
- ~
_ ~13 ,
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t
fILED Al~~~ qECORDFD '
, .ST. ~{{CIE COUNTY FLA. ' ' i
- Aact=~ ~~rr~,~s 4
~ CIERK C:~CUIT COURT . '
Rf[aR$ vrk~r;Ep ~
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E I FURTHER CERTiFY that I will register at my local address when the registration books reopen, and
~ comply w~th aU other requirements oC a legal resident of this State. g
i ' .i''_ ~
I FURTHER CERTIFY that 1 have no intention to return to my former domicile, and I intend to remain in ;
y . ~
` ~ ~~,~~-.c.~ , ~ ° , County,
Florida, permanently. ~~'~r~ %
~'~~``,...C~/~~~"'~-'-~~ ~ ~ ~ G~7'i~~fl.~
; •v,.... C'~ ~/~~~~~y~~>x' .
• •J ~ i v •
% (Name)
` ~ , i. 4 's
~ - " G: .
- C~.
E _ ~ . `I ~ ' , Q ' ~ ~
• " ' • ; ~ : (Addttss)
~ lr~' . i~ ~~r•!'`/ ~ ~i • '
•~'vi?orn.tc~~~d~s,u'bscribed before me this day of;
` 'r'^rC • :
; - - . . . A. D. 19~ ' ~
o .
~ ~ ~
` ROGER P TRAS, C1.ERK CIRCUIT COURT ~
I3y a~~.c~G D. C ~ntRJ.+~ 21 f
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