HomeMy WebLinkAbout2138 ~
Deciar~t~or, of Domicile ar~d Citizenshtp
TO Tt1E STATE ll COUI~iTY TAX ASSESSOR, ;~492~4
. ~
COUNTY, ~LORIDA: .
Tliis is my clcclaration of Domicil~• and Citizenship in thc St:tte of Florida that 1 am filing this day ~n i
accordance, and in conformity with Section 222.17, Florida ~tatut~~s. ~
I was fo:rnerly a legal resident uf .-~.L~'"~ and t
(CiiY) (Sla
n;sided at _~~~~G•-~_ . However, 1 have changed my domiciie to
(Street aud Numbrr~
and am and have bc.~n a bona fidc resident oi' the State of Florida since ~ day of
~
19_,7_~, and 1 reside at
~$Ireet and Numbet)
~~c~ ~~C~~li C~~.t~, ~ ' ~!Zl~fs~'..~!! County, Florida,
(Citr )
and this statement is to be takrn as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(lnxrl here any {+ertinCnt iscts, such u sble of pruperty or businrss, or relinyuishmeat of employment at former
domicile, remo~al of family to ne~v domicile, purchase of Aome, etc.)
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' 249254
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~'H~R CERTIFY that i will register at my local address when the registration books reopen, and
com'~~`~~{~~, r+~lh'all other requirements of a legal resident of this Statc.
1 FURTHER CERTIFY that 1 have no intention to return to my former domi ' e. and 1 intend to remain in
. ~;~~'os~'~»- • ---c~~~~~'`-- ` , County,
Florida, permanently. «'~y ~
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(l+iame)
~ _ ~0.~ _ C.__~_~.~c_ ~ B~!"'.'e,
~ (Addressl
~ Sworn to and subscribed before me thi~ day of
~
~ ~
4 ~ A.D. 19
~ - - ROGFR POITRl1SS, Clerk
~
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~ (To be r~ecuted in duplicate and onginal tiled with ('lerk Circuit Cou~t, and duplicate with Tax Assessor)
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- $a~K 2l1 P~~~ 2~.36 . , -
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