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Declaration of Domicile and Citi~~nsh~p ~
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"TO THE STAT ~ ATIU ('OUNTY TAX ASSl:SSOR,
, '
COUNTY, FLORIDA:
This is my derlaration of Uomicilr and Citizcnship in the State of Florida that I am filing this day in
accorcl:~nrr, and in conforniity with Section 2_'?.17, Florida Statutrs.
1 was formerly a legal resid+:nt ot - ' and 1
(CitY 1 (Sta~e)
msided at .~L~! ~~CtL~-~-.-,~GL4--1 Nowever. 1 have changed my ~fomicile to I
(Stre~et and Number)
and am and have b~~n a bona fide r~si~ent of the Stat~~ of Florida since day of
, 19~_~__, and 1 residr at ~.~~p~d ' -
treet and Numb
- ~__41~ -LL-------- • - ~ '~i~ County. Florida,
(city>
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida. •
(Inseri hrre any prrtinrnt facts, such u satr of proprrty or business, ax relinquishmrnt of nmploymrnt at former
don~icilr, removal of family to neN• domicile, purchase of home, rte.)
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ROC~q PO~tRAS
RF Ot~l~yFti F'jc~ ~OURT
~ B 10 29 ~'73
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~ 49~3
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1 FURTHER CERTIFY that 1 wiU register at my loral address when the registration books reopen, and
comply with all other requirements of a legal resident of this State.
1 FURTHER CER"I'IFY that 1 have no intention to return to my forn~er do ' ile, and I intend to remain in
- --~~'Ly~ - . County.
.
F~ ~ ~J~~~~°ently. ~u~>?
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~ ~ Sworn.iv'3nd subscribed beforr me this da~~ of
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~ ROGER POlTRAS. Cler _
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(To be e~ecuted in duplicale and un~:ioal filyd aaith ('lerk Circuit Court, and Juplicatr with 7ax Assessor)
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