HomeMy WebLinkAbout2691 rorm T. 1:-681-D--(SU~t--3-28-b?)
Dectarotion of Domicile ond Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR~
S%~ c r c COUNTY. FLORIDA : 218~9
1'his is my declaration of Domicile snd Citizenship in the State of Florida that I am filin~ thie dey in
accordance~ and in conformity with Chapter 222~ Section 222.17. Florida Statutea.
I was formerly a le~al reaident of----1Y_~. ~w: %~_+.'~_X~'~?t2./.- _..---'~?_~9. S_ -
(Ciq?) tsaa)
and I resided at.----?-l~. 1.-.-.!"Q-!g.t~~_~ ~_~_----._.._.~__I_. However, I have chan~ed my domicile
(3treet aad Number)
to and am and have been a bona fide reaident of the State of Florida eince . day of
- ='li--~~------- 19_.%_I_~ and I reside at _.~=r~7'--- ~--~-----•---'~-t~.~c._- ~-~1------------
_
. ~ . (Street and Numb~r)
! ~-*-L-fi . ~~~__?~~_'~~.~.t,.. ~',--------------•----------------County, Florida,
- ~tticr)
and this atatement ia to be taken aa my declaration of ~itizenahip, actusl le~al reaidence and domicile in
the State of Florida?.
(Insert l~sn an7 pertinent i~cta. such u sa1~ of property or Dusineas. or relinauiahment oi ~mployment at
form~r domicil~. r~monl ot tamjly to n~w domicile. putcl?asa ot homa. atc.)
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~ 21829~~
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~ FlLEO AMQ RECQRDED
SZ• luClE CO~JMTY FLA. ~
~ IIOCER POITRAS _
~ CIERK Ct?~CU~T COU~t '~1' '
~ REC4R0 VERtilEO~...---
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F ~ 5 11 ~3 AM'T i
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- I FL'RTHER CEKTIFY that I will regi9ter at my local addreaa wt~en the re~iatration booka reopen,
- and comply with all other requirementa of a legal reaident of thia St~te.
I FliRTHER CERTIFY th~t I have no intentaon to return to my former domicile~ and I intend to remain j
,
_
. ; - ~ ,
- ~ ~ .County, F'forida,
in_.. i--i- - ~ ~ ~ ~
_ (City>
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~2.:.:nently. ~ . ` .
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~ _'_'~S'~4"_~_ ~ t__~E.4 V~•~
_ ( Address) '
Sworn to and subscrihed before me thia.___.~...;__ day of ~ ~
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~ ------------------:~.~_.a.--~------____-__-------~___, A. D. 19__.?..i.
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_ \otary Public Stau ot ~oaii~ .t Lr~s
~t~ i:,.~~...~"~+~ - • : _ . ~
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,._z , M.r r~,-.~_'..~~.
Jiy Commiasion expirea -
_ (To b~ exccut~d in duyiinq ~nd ori~inal Al~d ~it1r q~rk Circnft CorR. aai duDllcat~ wii6 Ta~[ As~~saor)
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