HomeMy WebLinkAbout1040 ~ .1'7Q051
acl~ation ot Dorni~li~ and ClNse~ship
TO THE STATE MID COUNTY TAX ASSESSOR, ~
Si. LtJC1E COUN?Y, RORIDA:
Thit is my decls~ation of Oomicile and Citizenship in th~ St~te of Horida that 1 am Hlinq this day in aaoordano~ ~nd
in aatformiy with CMptK 2Z2, Settio~ 222.17. Florida Statut~s.
I was formsrly a lsyal resid~nt of a008YILL8 YD.
(~ity) (Stah)
and I ros~d~d At 402 eiaaaiora st. my
(Stroet and Numbsr)
to and am snd have been a bona fide msident of the Stata of florida sinos let day of
.Tu1F , t9_fifl, and I roside at 3221 S. Di=io Hir~hwa~
(Stroet a~nd Numbsr)
l~ORT lI~C~ SANit WCIE COUNTY, RARIDA _
and this ststement is b be taken as my declaration of citizenship, actual lagal residenos end domidle in the Shte of Horida.
(Insert here any pertinent facta, such as sale of property or bu:iness, or relinquishment of emplayme~t
at fom~e~ domicile, removal of family to new domiale, purchase of horrie, etc.)
~~s~xG oHir~ ig p~Lic saHOOL
B8II0$ P~TBIOt RB~D (9 yre) ~
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I. RJRTFIER !'~RTIFY that 1 will aomply with all othsr r~quinm~nts af a Ipal ~t of thi~ Stah.
1 FURTHER CERTIFY that I have no intention to retum to my former domiale, and I intend to remain in FORT
PIERGE, SAlNj WCIE COUNTIf, FLORlDA, permane~fly.
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_ _ ~
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~ . . . .
~ (Name)
;
- ; - JB'IEI.L BEED
.
; _ v 7 - tA~ddross)
_
N+d wbsuibed before me thf: 29th d~y ~ AII~iIIBT 19~_.
s~L^ .
RooNt
CL~K Notary Publk
e
8~? D.C. My Gommiubn ~xpirp
Ri M~aA~ M~Ikw aw~ Ni~M~I Ai~ vrNM Cl~k Nrr+~M C~w~, a~ ~ieM~ wti T~oc A~~.y
~i?3 ~1031
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