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Declara~ion of Domicile and Citizensh~p
TO TNE STATE ANU COUNTY TAX ASSESSOR,
_ _ COUNTY, FLORIDA: ~
11~is is my drrlaration of~Domicile ;~nd Citizenship in the State of Florida that I am Gling this day in
accordance, and in conl~ormity with Section 222.17, Florida Statutes.
1 was formerly a Iegal resident of l 1~ • -0'' and I
n) ~ (c~~r) ' (s~.<<)
resided at 3 ~'C /~(-t~:a n~ . Nowever, 1 have changed my domicile to
(Street and Number) '
and am and havc been a bona tide resident of the State of Florida since day of .
, 19~~, and 1 reside at 7~~ u
(Street and Number)
.
, ~.c.(`,,~ Q County, Florida,
(c~~y)
and this statemer~t is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Inseri here anr pertinent facts, sucA as sale of property or business, or «linquishment ot empioyment at tormer
domicJe, removal of family to oew domicile, purchase of home, elc.)
Applying for homestead
Entering children in school :
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FILEO Ar~ ?;EC~RUED
, . ST_ IUCi~ ~UUNTY FLA.
RQGE~ ~:;!TrAS
I CLERi( Ci~,i,t~IT COL'RT
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~ Ju~ 13 10 4i AM '73
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~ ~ 25fifi89
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~ I FURTHER CERTIFY that I will register at my local address when the registration books reopen, and
a comply with ail other requirements of a legal residcnt of th~s State.
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~ I FURTH CERTIFY that I have no intention to return to my former domicile, and I intend to remain in
~ ~ ' Q •
~ ~ . , ~ 1 Q , CountY,
_ Floride, ~iSr, er~., ~ ; • (c~~r) ~ ~',r.~.,-r++r•r c t} / .
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:-t '•~x ~ • ~ S,,t (Name) .
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r; ~ r'~R..;. (Address)
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~ Sworn t~i~aw~`r~,4t6~tt'hbcd beforr me this _!s.Z_ day of
~ A. D. 19_L,1.
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ROGER POITRAS, CIERK CIRCUIT COURT
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