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Deciaration of Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSCSSOR~
S~. LKtit CpUNTY, FLORIDA:
i
This is my dcct~r~tion of Domicilc and Citizcnship in the State of Florida that i am fding this day i~
t
acconiance, and in conformity with Section 222.17, Ftorida Statutes. ~
~
t was formerly a tegai resiuc~it c,i ~!~4~1/' ~ N~~ ~~'SPy and I_ ;
t
(Cicr) (saa) t
~o%r_ ~/~~s 1~!/' J~oa /"~f. ~/~l r'v~ . SIUWCYCI, : ~~a~~ M ~~UbMY ~omicile to
resided at _
tsa.~~ .~a Nr~e«, ~ht I,SfI,
and am and have been a bona fide residen of the State of Florid~ since da~ of
~'l~i1 ~ fo rCS%r/t ~~o /fo `viny a.y p~tr~nfs~ rt w~•s o~'/iC
NOd~N~ ber" , l9~ and I~~! V Sq F~ t`ii~'f O?!/'llwJ aJt~ q n~•. ~.sf~
~1 (Stnet and NumMt)
a~ MQr1(i l~C ~/~'lirr~as_ f~ ,~'Ori .l~ ~u~~t, .1~. LK~i C Couniy, Florida,
(c.~~r)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(~axrt Aere any pectinent (xts, such as sale of property or businas, or teliaquishmen[ ot employment at fo~met
doenic~e, remo~al of faa~ily to oew domicile, purchase of homs, etc.)
IQ~s~c,(~.,~ e .s ~.r ,f'~. L~,.~~'~ ~o~H ~r w~J pr~ v~oul/y ~s~~ ~/is ti~./
b n, ~af~it,~ A/frtd I'1~ ~h~r.~.~ ~n ~~n f~it Ju..,.,..~~ o~' /~7D~ •
y y ` ~ / -
A~ r?~1~~~ T~~~l I was JTi~~ C2 N.i.~o~. ~~i. ~c~ara~~~.~ o~ D~~~~~P
Ctr,.( Ci~~ jtnSHl ~/AI r~~~lr/ Ia-s./f /lCor~tc~ ~y ~/p~lr Of/'/l~ Or, ~O fJl~tyt~S!
~970 Qn.~ ~XQ p~tiC I'l~t..~ ~ 96 7~7. A S~Lc p Q~Or+ y~'{7! ~O ~/ON~ l.~q 6
..s J y ?
Of ~~C lL11`e! ~lon rla•ll ~ R ~ODo~ ~~6~ / ulj~ O.~ -
v
,6t~n Ik~~?~,~H~.~/ in ~.y or.+h H!?MC ~~taas~ 1
' 7~1;~ dtc~A~.~~,o., . -
~ ~ ~n~.~ N.u o?~~~ ~J~NC! h~r rA ~~ilr ~S Irt~l4~ ~[o.. r,.~af ~~~~a
; ~A,r~ a a y . .
~ i:, ~9'ro I Ja~-, ~y ~Crrs~~•l es~l/.s<~,.~ ~IDr~.~/4 r~r~•rP..~e
; - ~ r~ yt Q.~,~ ~~,«<6r /'~Qf~~rra,~ v?t~/ in~['.n~~on oF ~Qi.~f4~aive
f /b M'/ D~n . - .
~ rltt.lla~c' /,~~d Jy ?+~l Qf Q..t ~K or'.~ ST~IUCAE C~i~~
~e ROCEP. PJITRAS
~ CtERK Ct;CU1T CO(~RT{~\
RFCO~f~ VEqtFIEi~~~
a -~1 ~
~3 ~9 Zo AH'T5 ~
2.~~Q21
I FURTt1ER C~RTIFY th:+t I will register at my la:al address when the registration books reoprn, and
comply with all otli~r_rcquircmcnts of a lc~al rrsiJcnt of this Statc. _
1 FURTHER CERTIFY that 1 have nu intention to return to my former domicile, and i intend to remain in :
;
pOrf S~. Lu~it ~f. GuC iC , County,
Florida, permanrntly. ~tc~~r) ' ~
,~~2~~C ~ ~uru ~ r~c~ ~r.c..
~ - KfITHA~P/i?A L. ~NtEMf1N^~
. (Name)
~ ~~:~,-F, : S ~ % A~ ~,eE.v r~/. ~Nrc ~q~~
~ H'~' t::rL~ . ,~1~3 I~~.~~ C+~It i~tANY , . ~Ad~If!!f~
~ C/`~R ,Box S36 2
Sworn to and subxcribcd beforc mc this day of _
g~ ~ JU
r S~~ yo,~,~ D 56 3 3
~ahUOf I~I ~~C CC"~"+'-.tf9 A 9O "
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~ •t~',: r -~.-ES
~+a ~i u~s~ p ; " - ~
J~d~~ Ad~,i., 25 58-6849 • 0 R 2 J~ PAG~
. GA. 304'S8 • . . . ~ BOGK
Y ~dy Commission expires ~ = - . ,'r =
n _ : :
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i~ SiRiEi ST ,AiT. tii
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(To be eseculed in duplicale anJ uri~ein~l (ilyd with Clrrk f"!~i 1;o~w~ ~~~b T" A~~~
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