HomeMy WebLinkAbout0517 . Deciaratian of Domic~l~ and ~itixer~sh~p ~
1'v THE STATE~'D COI:`TY TAX ~1SSESSOR,
,
_ CO(1NTti'. FLORIUA: ~~~0
Thi~ is my dcclar:~tian of Domicile and Citizenship in the State of Florida that 1 am filing ihis day in
accord;~ncc, ar.d in conformity with Section i 7, Florida Statutes.
1 was formerly a legal nsident of _ ~Q,~ _ , ~L • and 1
(ci~r (state)
nsided at /1 . 1-lowe~er, 1 have changed my domicile to
(St~eet and Numb~
and am and have been a bona fide residrnt of the State of Florida since day ot'
~ _ . I9_~~ a:id ! reside at ~~~~~7~~C ~CT, _
~ f,j (Strett and Number)
.~c~~;.~.[~ LGr ~-----T--~~` . ~ 7~ /S l,~C - County. Florida,
(cit y )
and this stat~ment is to be taken as my derlaration of cifizenship, actual legal residence and domicile in the State
of Florida.
(Insrrl Aerz any prrlinnnt facts, such as sale of praperty ot business, or relinyuisfiment of employmonl st former
domicitc, retno~al uf hmily [o neN• domicile, purchase ~t home, ete.)
• I~~~ ~~.-P~ j~ (c ~ ~?/1
C~ n u. ~
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Fl6LED i!tD kfL'~~EO
ST_ R~s
~C ~~TR S~ . C
C1~AY ylnGl!'7 CQUJ~~' ~
RFCAq, vF?tFIEO~~,,,~~
~Fa 20 2 49 ~'M'73
~8140
1 FURTHER CER:II~Y that t wiil rr~ister at my lural addtess wnen th~ rrgistration books r.co~~.^., an~
compiy with all other requirements of a legai r~si~leni of this Stat~.
1 FURTHER CERTIFY that 1 ha~-e nu intrntio~ to r rn to my fornier domicile, and 1 intend to remain in
~ Dl CGE-- --~I ~ _~~G~GL-~-
- - - - - Countt .
Florida, permanently. ~ -
...........0 .
vJ1 ~ C~~ ' .
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v ~ ~v~jta~e,~ 1 r,,•P~ (ivam ) ,
:~3 ~ t`o' : _ _ ~~~'l~~l''I~7 ~~iG
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; ~ _ _~~~'.~.~c'~'
, , _
- ~ _ ~ , ~ (Address)
, • ~ ~
~ , , ~R~.:, p
~v~Q'~ to•~-~bed before mc this day of
• ~ /i;; ~ ~
-"'-T . A_ b. 19 -
. ~ ROGER POITRAS~ Cle~fi
-
_
;Sy Commission expires___
(T~~ bt rzecuted in duplicate and oti~;inal fJed with Clerk Circuit Coutt. +nd duplicate with Tax Asseswa)
~0~21~. ~ 5i7
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