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Declaration of ~ Domicile and Gitizenship
2'~5^s4 ~
TO THE STATE AND COUNTY TAX ASSESSOR, -
S7' L Gi G COUNTY, FLORIDA:
M?~ A R~
This is p~iy declaration of Domicile and Citizenship in the State of Florida that ~ filing this day in
accordance, and in conformity with Section 222.17; Florida Statutes.
Wt wEa~ WE
~ ~•wws formerly s legal resident~of V~N t u' ~r A" , ' and ~
~~y~y~ (State) ou r
resided at ~ 3 00 ~~~^i~r. - However, ; have changed ~ag domicile to
A ~ ~ (Street ~nd Numbet)
and a~ and have b~n 4 bona fide residents of the State- of Fiorida since , S 2! day of
w~ 6~ G o i~'
, 19~ and t- reside at _
(Sttaet and Number)
S-~. ~ ~ G,~ S-F' I_ ~ c~ C County, Florida,
(city) R ~
and this statement is to be taken as ~~ia,y declaration of citizenship, actual legal residence and domicile in the State .
of Florida.
(losert here anY P~*~~ent tscts, sueh as sah of propertr ot busioes. or relinquishment ot employmeat ~t tonaer ;
domicile, remoral of family to new domici~e. purchase of homa. ete.) . ~
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W~ W E hAVE 4d ou rr {
`I~ FURTHER CERTIFY that ~~1 register~ at my local addr~ss when the registration books reopen, and '
comply with all other requirements of a legal resident of this State. _ .
Wc w~ our w~
X FURTHER CERTIFY that~•have no intention to return to Itrit former domicile, and ~intend to remain in
~ Y-t St u e , Sf u G , County,
Florida, permanently. (c~ir) .
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Sw~~~,~i~~~~~~~e~ore me this day of
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.'t~: ~ ~ A.D. 19_.~~ -
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(To be e: uted in duplicate aod origin fJed with Clerk C"vcuN Court, and duplicate v?ith Tax Assessor)
. 80~ 2'33 ~ 19~0
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