HomeMy WebLinkAbout1611 Declaration of Domicile and Citizenship
24684'7
7'U THI: STATt~ AND COUNTY TAX ASSI~SSOR,
:
~J~ ('OUNTY, t~LOR1UA: ~
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Tttii is nty de~laration ot' Domicilc and Citirrnsitip in the State of Florida ihat 1 am tiling this day in ~
:irconlancr, ,ind in conformity with Scction _"?.17, Florid~ Statut~s.
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I was formerly a Irgal rrsidcnt oi ' • ~ and 1
- ~ lci~yl y~(scate) ~
r~si~icd at _ c-2G~ . However, t h:~ve changed~ domicil~ to ~
(Slrert anJ Numbrr) ~ f
an~i am and ha~~e hcrn a bon:~ iide residcnt of the Statr ~f Florida since day of
7!!~1~-- . 19_ and 1 reside at ---~y~ 3-----~,.io~~-'`~~~--- ~
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(Street and Numtxr) '
F-~' ~ - - ~ ~ - - . - County, Fiorida, :
(Cic.• ) _
.?nd this statement is to br takrn as my dreiar;~tion of ritizenship, actual legal residence a~~d domicile in the State
~,i~ Fl~rida.
(Insrr. here any pertinrot facts, such as salr uf prupetty or Dusinrss, or relinyuithment of rmployment at former
domicilr, rrmoval uf family to ne~v domirile, purchase of home, etcJ
24684~ ~
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• t~ ST
lUC1E COUMTY FEO
~ R „ LA.
~ OyE ~ ?~tTqAS
CLERK C:. rWt COtlRt
RFCOR~ V~~+: IFp„~,~~,~ _
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1 FURTHER CERTIFY that 1 wiU re~istcr at my local address wh~n the re~istration books reopen, and '
com}~ly with all other requirements of a teral rrsident of this State.
1 FURTHER CERT[FY that I havc no intention to return [o my forn~er domiril~, and 1 intend to rrmain in
:
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- - --~~~._r_
~z~=° Couiity, .
FloriJa. pern~anently ~c~~~`'~
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. CF„~- Edn~a`~ Fay~~`am~~ Gurd s - -
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(~ad~zss)
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Swora ,tnd subscribed beforr me this elay o1'
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. ' 'Q~C` ~ ~ _ __--,A.U. 19~~- • .
ei ~f ~
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- - - - - _ _ -
y Public State uf Florida at Lar~.
' l~~y COIIIIIlISS10R tYrITCS_--- "
(To be rarcutrd in Jup6cate :mJ ori~:~nrl filyd with ('lerk ('ircuit Cuurt, and dup6cate with Taz Assessorl
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-~x~G~ ':r v a.~.-..,~y M.