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Dectar~~iQn ~f ~~~~iC~~~ ~r~d Citizr~nsh~p `
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'I'O T1iC STATE ANU COUN'fY TAX ASS[:SSOR, ~
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~~-u-Gw COUNTY; f~LORIDA: ~
'il?is is my dcclaration of Domicilc and Citizcnship in the State of Florida that 1 am filing this day in
accordance, and in conformity with Section 222.17, Florida Statutes. ,
I was tormerly a Icgal resident of ~===~-=~-'l-~` 4'' and I
• (citr) ' (31ate)
resided at ~y~s ~ . However, I have changed my domicile to
(Slreet snd Number)
and am and have been a bona fide resident of the State of Florida since day of
~y, ~J :
, 19r3 ' and 1 reside at v,C tap~
(saFe )
~ ~~~-c_c~ , ~ County, Florida,
(cy~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 anr perlinent fscts. such as sale ot property or business. or relinquishment of employment st forma
dapic~e~ removsl of family to new domicile. purehase of home. ete.)
• ' _ -
Applying for homestead . . . .
~ Entering children in school : ~ A- ~ ;
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~u-t. 26~9 ,
, F1LEU,~~4 kECOROED s
. • . ST. ~UCIi: Gr)UMTY FtA. ~
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' CiFati ;:?-CU17 C~URT • -
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I FURTHER CERTIFY that I will register at my local address when the registration books reopen, and
~ comply with all other requirements of a legal resident of this State.
~ 1 FURTHER CERTIFY that I have no intention to return to my former domicile, ar~d I intend to remain in
~ ~~c.~~ - ~ .~c.c.c,c.,C. , CountY~
" Florid~,•p~neqtly. (cny~ '
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J?`• ~ ~ Q ~ (Address) ~
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~ Sd"i?oitti.~d am~su6sca~'bed before me this day of
~ ~ ~ 3 ~
A.D. 19.
~ ROGER PO RAS, CLERK CIRCUIT C~URT ~OK~'1 ~i413 -
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