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260539 ~
~~-:C~~~'c~~~~aCl ~'f?~1C~~~; c'~~'~~ ~~~i~~i'~S~(1i~ .
"f0 TI C STATE ANU COUN'1'Y TAX ASSL'SSOR, ~
~ . . . w.
COUNTY; ~LORIDA:
This is my dcclaration of Domicilc and Citizcnship in tlic Statc of Florida lltai I am Cling this day in
accordancc, and in conformity with Section 222.17, lorida Statutcs.
. ,
I was formerly a lcgal resident of ~
- . (~1tr) ' (state) and I r
resided at ~ aC5 f
c-K-~- . Howcver, I have changed my domicile to ~
(Street and Number) . _ ~ ,
and am and have bcen a bona fide resident of the State of Florida since --Z day of
, 19,~~ and I reside at L~D~ a~-•~.v /Jr ~
~ (s,reec~n umber)
, -u-~-~-~- County, Florida,
(c;ir)
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 pcrtinent facts. such u sale oi prope~ty or business. or relinquishment ot employment at former
domicile. temoval oi family to new domicile. purchase of home. etc.) ~
• ,
Applying for homestead . _ .
~ Entering children in school :
- ~ ~c..~,v ~ .
•
` ~'~c' ~ . .
;
u~- ~ ~ ~ x~ ' a~ 2sC~539
a~ .
• ST
~UCIf C4UMTr f1A.
ROCEN aottA~s ;
- ClERK C: ZCUIT COURT '
RFf.pRC ~Ek+i'IQO~` ~
- Auc 6 I 3s PH'73
~
~ ~
~ ~ - ~
I FURTHER CERTIFY that I will register at my local address when the registration books reopen, and
comply with all ot}~er requirements of a legal resident of this State.
~ .
. I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
p~~ ~ J,~~~~
Florid c~~~r) , County,
.,a~, .p~~;rnanently.
. ,
.
- i C.~
, _ C;Q%. .
_ ' i ~'~,~•,~'r~~.. ' . -
~ ~ ~ v ~ ~ ~ ~Gt~Y~-c~ ~ ~amej ~,~c.i~i-..c~
~ ~kVr."• . ~ . ~D
N~ ~ j ~ ~ j r ~ ~/?ddtess)
~S 'to•u,~ ~i'b~sctificd beforc me this ~ ~ da ot ' ' `
•~°i'~ ~ e ~ , y
-
...i ~ A. D. 19~~ " .
~ ROGEK P TR/1S, CLERK CIRCUIT COURT
'J R
By Q..~~C~.,C.. (o D . C R 21/ ~ ? , ~ . ~
~^C. '
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