HomeMy WebLinkAbout2276 ~i
aeciaration of Domi~i=e and Citizenship
1'O Tli : STATE D C'UUNTY 'i'AX ASSE:SS4R, 249361 i
;
__l_~. COUNTY, FLORlUA:
Tl~is is my drela~ation ol~ Uomicilr and Citizenship in thc Statc of
Florida that l am tiling this day in
~ccorJancr, and in conlormity with Scction ??'.17, Fl~rida trs. -
. ~
I was t'onnerty a I~gal residcnt of _ _ ' • - ~nd 1
(City . (State)
rrsi~ted at - . How~ver, 1 have changed my domicile to
(Strrit and Numbrr)
:~nd am ar.d ha~t• txcn ~ bona fide residc.•nt of the Stat~ of Florida since _ day of
. - G~ '
- - , I 9_ an~ 1 reside a1 ~f~
~I' ~O n Q~ _
(Strret and Namber) ~
.
~.C-c t.
~
-L~~:e~ _ t.is County, Florida,
tc~~, >
and this statement is to be taken as my dcrlaration af citizcrzship, acie:a! lebal residence and domicile in the State
ut~ Florida. -
(Insrr: herr any prrunrnt facts, such as s:?Ir o( property or Ausi~rss, or reli~yuishment of rmploymrnt at forme~
domicile, remotal uf family to nrw• domicile, purchax ut home, rtc.)
~h.~--u.,~~"~'tzl~' FILEO A~i~ iECtlR0E0
ST_tUCi_ 4~~~TY FIA. t~
ROC_ ~ ~J1TR,~S ~
CiERK C.-;.~;i ~p~RT
RE_r.o?~ v-t•~;f~
~ ~ 4 35 P~ '1~
249~61
I FURTHER CERTIFY that 1 will register at my lo~al address when the registration books reopen, and
~~mply with all other requirements of a legal resident of ti~is State_
t Fl,'RTHER CER th~st 1 ha~~e no intention to return to my former domicil , and 1 intend to :~main in
- - - - ! - Gz/
- ---s L'ounty,
~~b~r~~;,~~~ . tc~~. ~ - -
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: fi : ia: - . • -
(Name)
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r • • --.~.1! i.••' v.~ ' ~ L[ h f ~ ~j
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i~ : ~ - - - - =
~ 1 . - -~4+iddres5t'
- .~o s,_ _ _
Sworn ~t :~nd subscribed before me this day of
_ .~"JCG~/ C~1~-- .
_ - A.D. 19
ROGER POITRAS, Clectt ` .
~ ~'S ~--~~~i<-- -v~~c~i Gii~ d00K~~~ PaGi~~~~
(Tu be rxecuted in duplic-r1e anJ ~~t~}i filid with CIerA Circuit Courl. and duplicate with Tax A~uw)
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