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Dectaration of Qo~:c~t~ and CitiZensi~jp
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TO TNE STATE AND COUNTY TAX ASSESSOR, , ;
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~L ~Cu`Cs~~ COUNTY, FLORIDA: , ~ ~
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This is my declaration of Domicil~ and Citizenship in the State of Florida that I am filing this day in ~
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accordance, and in conformity with Section 222.17, Florida Statutes.- ~
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1 was formerly a legal resident oC M r~'t m c _ , e,~? _ and I '
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resided at .~n'~G'~ J~~~-- C'iau~.f" . However, I have changed my domicile to ;
(Street sod Num~er) 3
ansi am and have been a bona fide resident of the State of Florida since Ja<< day of ~
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J,~ ~u ~r ~C'u , 19 , and 1 reside at .r'~as~.~ r t~:iiiQ rL`~i ~ ;
(Start aad Number) ~
,ro~ 1 ~
f ~ UC ~,r' l _ ~.`-1 t.( r~~ ~ ~ ~ County, Florida, `
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and this statement is to bc taken as my declaration of citizenship, actual legal residence and domicile in the State s
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of Florida. . • s
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(Iasect Aere sny pertinrnt facts, such as sale oi prope~tr or businas• or re~inquishment ot empioyment at tormer
dpmic~le; temoral of familr to new domicJe. purcAase ot Aome. etc.)
Applying for homesteaa
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?Entering children in school :
,P~b~?,~ t ~~,Ti~~,~ ~ r~~rJ~~_~ ~
r'` e Ju. ~ t /t'(~ 1'n Ty k'~1--~ ~ ~
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. ~~~t~i~~ o~T~f . ~
i - ~~ERK Ct~G{~It CpURT L ' °
~ R~COR9 YEf~i1~p ~
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290262 '
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I FURTNER CERTIFY that I will register at my local address when the registration books reopen, and ;
camply with all other requirements of a legal resident of this State. -
I FURTHER CERTIFY that 1 have no intention to retum to my former domicile, and I intend to remain in
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lC~'1 ~=T ~.;~i ~C _ fC.k i ..T ~_uC~~~ -s COUIIty~-
Florida, permanently. #
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- ^ ~ (Name) / ,
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~';s . = ~1~,~" ~ e~ ~u. j~CI t c• . ~,,~~t 1 J ~i~~~ = -
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~:Swo~n ~o and~~cribed before me this ~ day of :
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~t A.D. 19-~'?
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,r; ~:I~~~Zi J • '`'a.{%` ` ' ' • i
ROGER PbITRAS, CI~RK CIRCUIT COURT ~ ~
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