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~ Declara~ion of Domicite and Citizensh~p 1~'
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TO THt: STATE ANU COUNTY TAX ASSESSOR, ~
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' T C v~'C _ COUNTY, eLORIDA:
Tl~is is my dcclaration of Domicilc and Citizcnsi~ip in thc Statc of Florida that 1 am filing this day in
accordancc, and in conformity ~vith Scction 222.17, Florida Statutes. •
1 was formerly a Iegal resid~nt oT t~s r~.~,/n/ s,-,~ • e~ , and 1
(city) ~ (st.te)
resided at ! Z~ o r s ~9 d~ . However, I have changed my domicile to
(Street and Numbe~)
and am and have been a bona fidc resident of the State of Florida since sf z~ day of
, 19?
3~ and 1 reside at
(Street and Numbet)
r S s.^ ~ u~ ~ r , County, Florida,
(c~~r)
and this staiement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida. ~
(Inseti h~re aoY Prttine~t facts, such u sale of property or business, or relinquishment of employment at former
domicile, remoYal of family to new domicile, purchase ot homr, etc.)
Applying~Qr hom~stead
Entering children in school :)~,,~~~y C~,~ S a
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RECQRD V R~ f1ED ~~7"~I
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~i A~!'13
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~ 2~91~
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1 FURTHER CERT!! that I will register at my local address when the registration books reopen, and
comply with all othcr requi:~n:ents of a le~al resident of this State.
s
~ I RTHER CERTIFY that ! havc no intention to return to my former do icile, and I intend to remain in
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= ~ - • , c=G~ , County,
~ ~`lorida, permanently. ~ ~ji'L soN~
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: G;? CUiI ' ~
, ,
~ ` ~ (Name) ---T
J ~ • ~ ' . :_s••,.~.. G . .
~ ' ~ a~~•~ I ~ S
> ;y - - ~~Z ~v~~' r
~ . j " ~ -T _ ~ ddress)
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' `•'Si • .
Y ~ •Q , ~4 - ? I
~ ~~•~9b~ ci~fid
~~C,~~cd before ~nc this day of
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~ . A. D. I 9
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; ROGEK POITRAS, CLL•'RK CIRCUIT COURT
~ By ~ D . C ~0 ~ ~1 ~ . : 2~.r .~1~ .
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