HomeMy WebLinkAbout0090 Declaration of Domicile and Citizenship
TO THt: STATE AND ('OUNTY TAX ASSk:SSOR. 241558
1'. r 1 rt_G~-~_ COUNTY. FLORIUA:
Tl~i~ is my drelaratiun of Damicile and Citizenship in the Statr ot~ Florida that 1 am Cling this day in
acrora.in~r. and in contormily with Sc;ction _'_'~.17, Florida Statut~s.
I was fornierly .i I~gal r~sident ot~ Q~~4 e -ttlC~-__ . ----~o• :~nd !
(CiIY) (State)
msi~lyd at J~~_ ._W __,~c.,1,rz~_1 ___St ______~_~__1-_ . However, 1 have changed my domicile to
(Strrrt and Numbrr) ~
and am and have br~n a bona tide nsid~nt of the State of Flocida since _ day of
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- !~Q_~-!, - . l9. 7_2. and l rrsid~ at -~--3 --.2°-~--~~~
(Sttett and Numbet)
_ _ ~1'c~ - -=--~~-~-ci-,G County. Florida,
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and this statement is to be taken as my dcclaration ot~ citizenship, actual legal residence and domicile in the State
of Florida.
(Insrr~ hrrc an~• prrUnrnt facts, such as ~alr of pruprrty or businrss, or rrlinyuishment oi emplorment at former
domicile, remo~-rl of family tu ne~v Jomicile, purrha.ce of home. ~tc.l
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[ FURTHER CERTIFY that 1 will 'register at my loral address when the registration books reopen, and
romply with all other requirements et lf ICL~I icSl(3tllt Of i}liS St:ltl'.
! fURTHER CERTIFY that 1 ha~•r no intention to return to my fornier domicile, and 1 intend to remain in
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~ Florida, permanently. ~c•"> ~ r~ _ ~
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(Name)
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~ Sworn to and subscribed brfore me thi; d~' _ day of~ '
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'4,- - - - . A_ D. 19 ~
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~ SI ry Public State of Plorida at e -
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,/~=,~'•.•••T~!=~~ C,` r' (To be exrcuted in Juplicatr and ongina! filyd with ('Ietl. Cireuit Court, and duplicate with Tax Assessot)
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