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Declar~tion of Domicite and Citizensh~ip
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TO THE STATE AND COUNTY TAX ASSESSOR, ~
~i. ~e!~.~.~,~~ 2~~4~ . - } .
_ COUNTY, FL.ORlDA: !
Tbis is my drelaration of Domicile and CitiZCnship in the State of
Florida that I am filing this day in ~
accordance, and in contormity with Section 222.17, Florida Statutcs.
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1 was formerly a legal resident of -~~(~c..x.r~a~~ , ~J `'-~u' and l
(Ci~r) (state)
resided at _la 3 2 /9c~P . However, 1 have changed my domicile to
(Sir aod Number) 7~ ;
and am and have been a bona fide resident of the State of Florida since day of ~
i-
, 19~`3 and I reside at ~ ~ S~ ~ ~ ~ /~-*~c ~ •
. ~ (Strett and Numberj ~
• , ~Z` - '~tc ~ c c County, Florida, ~
(csir) ~
and this statement is to be ta[cen as my declaration of citizenship, actual tegal residenee and domicile in the State
of Florida. -
(Insert here aey pertinertt facts, such ss sale ot property w business. a reliaquishment ot employment at [otmer
domicile. remova! ot family to new domicJe, purchase of Aome. etc.) -
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Applying for homestead
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~Entering children in school ; '
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AECOAD VEF!~f~Dr...~++~+ ~
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1 FURTHER CERTIFY that i w~ll register at my local address when the registration books reopen, and 3
comply with all other requirements of a legal resident of this State. s
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I FURTHER CERTIFY that I have no inteniion to return ta my former domicile, and I intend to remain in ~
~ - ,~.c-e.~.-c~. 1v~~c,c.c,c..e , County, s`
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Flq~ji~, $@~i!ently. cc~~r~ ' :
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: ~~r~a ~ ~ . ~ (Name) :
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.w,':-_gF.~f'_Fa i1:e' ~~7 O~ifiQ~ll.-~ y-~ `LL~~~ ~
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S ~i~o ~hd~~ubscribed before me this °z~ day of ~ -
. D. 19~ ~
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ROGER POITRAS, CIERK CIRCUI COURT #
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By C p~C ;
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