HomeMy WebLinkAbout4001 2442'72 ~ ~
Declaration of D~micile and Citizenship
TO THE STA~'F ANU ('OUNTY TA~C ASSf:SSOR.
C
-L~I_ .~~~-s,.~ - _ _ ('UUhTI', FLORIi~A:
Tf~is is my dcclaratiui~ oi vomirilc .,na c;~;~~~~,n~r in tlir Stat~ of Florida that I~m tiling th~s day ~n
:iccor~lancr, .ind in cont~orn~ity with Se~tion _'_'_'.17, Florida Statut~s.
/
1 was i~ormcrly a Irgal rrsidrnt ot~ ff t.~f'~ ~,1.'!~L .~_~~t~_L~~ ~_SL and t
~ ~~~HYI (Sta1e)
nsided at /~~'._~~.}(.~_2 . Nowcver, t have changesi, my domicile to
(Strr~nd Numt+rr)
~nd am and havc h~rn a bona li~l: rrsiclrnt o1 thc State of Florida since / day of
-.LL-~ ~Y~-- - . 19 7' and 1 r~sidc at ~'q_~ ~_S~
~r Ti4
~ ~ (Strret aod Number)
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/ - T-- County, Florida,
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and this statrment is to be taken as my dr~l~ration ut citize~ish~p, actual tegai restdenc;e a~tu uu~niciir i~i ii~r ~iaic
of Florida.
(lnsrtl herr any ~+rrtinrnt lacls, ~uch as ylr of prnprrl> ur bus~n~u. ur rclinyuishment ot rmplo~ment at tormer
domicile, temu~al of latnily to nc~v dumicile, purcha>r uf humr, rtc.)
4Ve have movea here and do not intend ;o live or state our residence
at our former address in Wisconsin
fl 0 A!!D RE;C
§ ROCER
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CIERI( C~R4Uli ~,qg~~
RECORD YERiF1E0 U
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~.442'72
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I FURTHER C~KTIFY that I will r~~istrr at m~~ loc.ii addrrss when the registration hooks reoren, and
comply with all othrr requir~m~nt, c?f Ie~_al r~sidrnt of this St~te.
1 rURTHER CERT(i~Y that I ha~~ ize> int~ntirn~ to return ro my forn~erdomicile, and 1 intend to remain in
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_ __L.1'1~~~T- L-- • - 1- - Co~uih~.
' Flori~la, pern~ancntly.
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(Name)
:
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; ~ T/7~~// f~i~_ -SC /~l
~ J Mdd
Sworn to ar~d suhs~ribed bcti~rc ~~ie this ~av c~f `
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t~ • ot~SuAlic Statr of I I~~nJa a .arF~
' ~ ~ : ' ,-j : ~ : ~ : : 21~i1:.~ P~idli~ Si,ATf Qf il~iDA AT IAR6E
€ = • ' ~ ; ~ : , I~~ ~ CUINMtSS1U1V EXPIN~S fEff. 16. 1973
~ • 1?,t Bt:......y ~:.~~1t~~;r~,~ ~Oli'0[~ IHW fRFD N. DIESIELWNST
` .°t1 yYS~.y~..S.,.y al- _
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t~S ~`,~~•``(Tu be r~rcutrJ ~n Jupl~ca~a rnd ~~r~~ in.~l filyd «ilh ('lerk Circuit ('ourt. and duplicatr ~~ilh Tax Assessor)
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F :~:~r 20~3 ~94
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