HomeMy WebLinkAbout1367 ~48~~9 K"
Dec~ara~t~an of aomicile and Gitizenship
TU TH~ STA'T~ ANU COUNTY TAX ASSl:SSOR,
.
COUNTY, I~LORIUA:
Tltis is my d~claration of Domicile and Citizenship in the State of Florida that t am filing this day in
~cconiance, and in conformity with Section ?'_2.17, Florida Sta'utes. , '
! was farnierly a legal resid~nt of ~-~~-~~u-• _ and 1
(Cit y ) (sace)
n~sidcd at p . However, I have changed my domicile to
(Street and Numbr~)
. _
and am and have bccn a bona ~de resi~icnt of the State oP Florida since _ day of ;
• :
. 19 and 1 reside at q-~~C-~- ~-r ~
~ (Street and NumDer) f
?J•C ~~I.[' ;Q , County, Florida,
~~Y~
and this statement is to be taken as my dec~:~ration oi' citizenship, actual legal residence and domicile in the State
of Florida.
;
(Inseri herc any perlin~nt facls, such as sale ot property or business, ot reiinquisAment of employment at former
domicile, remo~sl ot family to neN• domicilr, purchase of home, etc.) j
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1 FURTHER CERTIFY that I will rcgister at my loc~al address when the registration books reopen, and
comply with all other requirements of a lega! resident of this State.
I FURTHE RTIFY that I ha~e no intention to return to m~ former omicile, and I intend to remain in
-u~ County,
1 _=y'I~i~~_-. ^ '
F~olida,~Per~att~t~j~tiy- (c~i}~
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~ ~ . • ~„r~i : G; ~ ~ . - - - - - ~Name)
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S~dorq'ba ar~,etlbscribed befare me this l~ day af
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~ ~SC~~~ _ - - ~ A. D. 19 -
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(To be exrcuted in duplicatr and ori~in~ filed wit Clrrk Circuit Coutt, and dupli.ate with Taa Assessor)
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