HomeMy WebLinkAbout4079 Declaration of Domicile and Citizenship
2443~0
'TO THE STATE ANU C OUNTY TAX ASSI:SSOR,
~ L._c~c _ _ COUNTY, FLORIDA:
This is my declcir.~tion vf Domicile :~nd Citirenship in the State of Florida that I am filing this day in
,~~~~..r.i;,n~_,•, :~~td in c~nPnrn~itv with Section ?~2.17, Florida Statutes.
1 was formerly a Icbal resident of'_____~~1~TS~A~-E ,~E w~V~'` and 1
~ (Cily) (State)
residcd :~t ~ /
h~°
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~C.dCtCs~~7S - However, 1 have changed my domicile to
(Strret and Numbrr)
and am and have bc:~n a bona fide resident of the State of Florida since day of
L . 19_7Z , and t residc at I 7 .3 ~ Ei ~/L /9C/~t~/I
(Sireet and Number) ~
~rt f ~u ~ ~e__}-~~ietc~_, _ Ct ~ / County, Florida,
(CitYi
and this statement is to be taken as my declaration ot citizenship, actual legal residence and domicile in the State
of Florida.
(insrn here anY tiertinrnt facts, such as sale of proprrty or business, or rclinquithment of employment at fotmrt
domicile, removai of family lo new domicile, purchase ot home, ete.)
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$T. IUCiE C~UMTY f~
CL RRCC RCUIt COURT ~
RECORD VERIFIED- J
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244320
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~ 1 FURTHER CERTIFY that I will mgister at my loral address when the registration books reopen, and
~ romply with all other requirements of a legal resident of this S[ate.
~
~ 1 FURTHER CERTIFY that 1 have no intention to return to my former domicile, and I intend to remain in
~
~ ~r~~l.LG~--1_._ / . _~.~Yc- ~l ~ L< t°_ County,
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~ Florida, pernta»ently. ~ x ~c ~
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(I~iame) ~
_ /7.~ ~j"dC,(~P~ ~a_l,~ /Or~ .S'. ~i c~ '
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t (Address) ~~~G~lr'~ F/0~' i
" "~•r.
^ Swoc~~ tq~yyid sit~ribed before me this day of ~
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~ ' e~~=~- . A. D. 19 7
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~ _ % , ~ . ~ .t ~y ~li~ > e o( Flunda at I.aree `
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~(To be rsrcuted in dupl~catr and ~.r~~:inal filed with l'lerk ('ircuit Coutt. and duplicate a~~ith Tax As.secsor)
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