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Dectaration ~f Domicile and Citizenship
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TO THE STATE ANU COUNTY TAX ASSESSOR,
.
~0~2% 5T 1-~~~F COUNTY, FLORIDA: ~ ~
, ~
This is my dcclaratian of Domicilc and Citizcnship in thc State of Florida thaf 1 am Cling this day in ~
accordance, and in conformity with Section 222.1 Florida Statutes.
/l/ E C Ni4 tf , W~~ C e and 1 ;
I was formerly a legal resident of
(~~r) (stace)
resided at ~ y~ ~/1-o vE Si . However, I have changed my domicile to
(Street and Number)
and am and have been a bona ~de resident of the State of Florida since day of
" ~ , 19-
-13
- and I reside at
(Street and Numbcr)
, County, Florida,
(c;tr)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
(Inse~i hcre any pertineot facis, such as sale ot property or business, or relinquishment of employment at formet
domicile. removal of fsmily to new domicile, purchase of home, etc.)
Applying for homestead
Entering children in school ; -
~~?-~,.s-_ ~ w~~~a~ ~a.~v.~ ~ ~o~~
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~ fIlE9 wtli3 RfW1~E~
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; ~Q ~ t o o ~j sT ROCE P01ZRJ1
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j r. ~P~,~W CLfRR CtFtU1T COURTm ~
~ S~ 3{ 'Z 3 9 RECt?R~ YE~i=tEQ...~L~
~ ~ 1 L~ C 1{Z.C S~ ~T S
~ o 0 3~- 1b 8 33 ~!'73
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` I FURTHER CERTIFY that I will register at my local address when the registration books reopen, and
~ comply with all other requirements of a legal resident of this Statc.
~
~ I FURTHER CERTIFY that I have no intention to return to my former domicile, and 1 intend to remain in
E ~o n-
~ FT l, v c~~' !~2`~- S7- l. v!~~ , CountY,
~ Florida, Rermanently. «"r~ obarr _ tda•.KEk
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3 1~ l1M~y~ ~ 1~I. ~S}. ;
: : V~ '~V:, (Name)
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J~~ ° N ~ ~.c. ~ ti2Fs ~ t~TS ~ M~
a ~ S~t, ~~$~itl~tibed before mc this day ot
= CG•• i
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R _ A.D. 19 /
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~ ROGER POITRAS, CIERK CIIZ~U T COURT
~
By D. c ' Soe~ i~~5 r ar.:
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