HomeMy WebLinkAbout1710 Decla~ation of Domicile and Citiienship
TO THE STATE AND COUNTY TAX ASSESSOR, ~Zi1Z98~s
_J%r
-,~.t~c _ i _ COUNTY, FLORIDA:
This is my decla~ation of Domicile and Citizenship in the State of Florida that ! am Gling this day in
accorJance, and in conformity with Section 222.17, Florida Statutes.
1 was formerly a legal resident of _r0~~ vG~-'NS ~~~~~'~AD~ and 1
(ci~r1` ' (stsce)
nsided at _~~s h-%~~ WC~~'D ~R'~'~= . However, 1 have changed my domicile to
(Street and Number)
and am and have been a bona fide resident of the State of Florida since t~~• ~ Z' day of
fE~ k ~2 3 ~1
l9 7z _ and 1 reside at ~ ~
(Street and Number)
~~2 j ~/r= i2~,E , % - ~-~t C/~=- County, Florida,
(c~tr)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(lnxrt I~ere any pertinent facls, such ss sale oi property or business, or relinquishment of employment at tormer
domicile, removal of tamily to new domicile, purchase of home, etc.)
~u C: S r~ U~ ~OMr` -
229876~
ota ~o~ $
BIER C~~CUIf CO{l~If
RECORD YE?~1FIE~~
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I FURTHER CERT[FY that 1 wiil register at my local address when the registration books reopen, and
comply with all other requirements of a legal resident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
~o~% P~~ ~ _ _ , ~ - ~ ~ ~ ~ , ~ounty,
Florida, permanendy. cc~tr~ -
(I~-~'-' C1(>ti`' /
.~Jl" , ~SC/4/~ (Nsme) 6/eL
_ _ 3 J~,~ v~ ~
~ - ddress)
; v
~rn.to ar~d ~u~scribed before me this 'z ~ day of
; .ti c.~,., A.D. 19~.
O%L
o~c~r~
y Public State of Fiorids at Lar6e
NOTARY PUdI~C. S1ATE d~FLAR1011 M lAR6E . '
My Commission expires TM~
~~n~ u~t ~ iKN
~ -
(To be executed in dupticate arkl o~i6inal CJed with Clerk Circuit Court, and duplicste with Tax Assesw~)
e oK 202 PACr 1709 ~
A(~(~ Form 71-22
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