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ST, IUCIE COlgiTr, F A
Declaration of Domicile ~-an~ citizenship
TO THE STATE AND COUNTY TA% ASSESSOR.
3T LUCI$ COUNTY. FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am Sling this day in
accordance, and in conformity with Chapter 222, Selection 222.17, Florida Statutes.
BID COUNTY
I was formerly a legal r~eaident of-------------------------------------___---------------------------_. _--_--~---------------------------
(Cib) (State)
and I resided at_ 22?~--fleao2L_$t.._-------------------------_--------- --------- However, I have changed my domicile
it~eet and Nnmbar)
to and am and have been a bona Sde resident of the State of Florida since ~ -=}-- - __-___-- day of
------------..°__~. and I :~idc at-_I3~_ N.- I2~Ch St. _ .
(8treet and Nnmber)
------ FT. _P~ERCE -----• -------. ----~~-1--~-~I~----------------------------------County, Florida,
icity)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domidle in
the State of Florida.
• (Insert hare~ say pertinent facts. sneb as sale of proper it ~ ~~o~relinQuiiLment of employmeat at
tormer domicDe, removal of family to new domicile. pn chase
91131
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Si. tUC1E COt~Nit, F~G~~.•-:A
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I FURTHER CERTIFY that I will register at my local address when the registration books reopen,
and comply with all other requirements of a Ie2aI resident of this State.
I FURTHER CERTIFY that I have no intention to rwt»r~+ to my tprmnr rlnmirilP, an$ I irltPn~i to r~±m$in
~iy~n.p.,~~y~,~~-~-~-__~- ~--- --.__-____., ST. jtUCIE -_ ______County. Florida.
V :. ti - - ~~', t ~' (Name)
e c ~'„ •1 ~ ' ' _ B3E [ITS
..: •.: ~ s
to~~d:~~eeribed beZaa~s me this_ 3rdday as .
t-
p. Cleric
>ti~jr Commission
(1b be ezeented in doylieab sad oeialeal Ned will CMek Cinoil Coon. esd dustkate will T~ Asaeaaoe)
sows. savor ow. r~s.t cks, iris.
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