HomeMy WebLinkAbout0144 L?~cl~rat~ar~ of t~omic~le and Gitizensh~p
TO THE S7~ATE AhU COUNTY TAX ASSESSOR,
~ - COi1NTY. FLORIDA: 24~86z
Tlii~ is my declaration of
Domicile and Citizenship in the State of
Florida that 1 am filing this day in
;
accordance, and in canforn~ity with Section ~22.1 Flurida Statutc~s.
I was t'ornierly a legal rcsident of S~/'~ _ and 1'
(CiIY) « i)
msidid at sS~_Y' e~
r" . However, l have changed my domicile to
(Strert and Number)
:~nd am and have been ~ bona [ide rrsident ot' .the State of Ftarida sin~ day of
- - - - • 19 and I msid~ at i~ ~ C` 3 ~ cz ~ o C~' ~
(su~~ ~~a h~~ex~)
~,cc.~YGe , ~ ~iL~-~--Q Caunty, Florida,
- (c~~r)
an~i this stateme~~t i~ io ..~ken as my declaratic~n of ~iti7enchip, actua! legal residence and domicile in the State
of Florida. ° -
(Insert here any prttinrnt facts, such u sale of property or businrss, or rclinquishme~t of employmrnt at formr:
domicile, removal of ~aenily to new domicile, purchase of home, rtc.)
a.ea° "~=%~~,,'~et/
1
~tMYE Ct~ n~1t~~ ~ -
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CLE1t1t G?r,WT COU1tT -
RECOR~ ycp,c~f~
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I FUR'THER CERTIFY that 1 wili registcr at my lacal address ~vhen the m.gistration books reopen, and
~ comply with all other req!~irements of a legal residcnt of this State.
I FURTHER CERT[FY that 1 have no intention to return to my former domiciie. and t inte^.d to remain in
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--.Y
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e _ ` 4; : ~~dM • i ~•Z r Z~ ~~Iame)
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` (Address)
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'~3r~,!o~t~er~~~µfi~cribed befor~ me this ~~-day of
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~ ---~~z~~ - A.D. 19~ -
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~ otary PuWis State of flon t I.arFe ~
i
~ 6~? i
~'[y Commission expires~ s~ t
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(To be cxecuted in duplicate ~nd original filyd wilh Cletk ('itcnit Court. an~ dopl:cate ailh Tax Assessor)
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B~OK
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