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Declorotion of Domicile and Citizenship, LUCIE couNTr, FLA.
TO TAE STATE AND COUNTY TAX ASSESSOR,
~ ._LIIC~ COUNTY. FlAEIDA: -
Thia is my declaration of Domicile and Citisenahip in the State of Florida that I am lUing this day in
accordance, and in t;,onformity with Chapter 222, Section 222.17, Florida Statutes.
I wse formerly a leral resident of________8I83tZ.I~-- (cyq-) ------- -------------• ----------- ~St.~, ~-----
and iresided at---~Qed-- st-•- -M~~tRud Nn~m~beri --------------- ---- - ----- Aowever, I have changed mY domicile
~ -4- -- - --------..day of
to and am and have been a bona 8de resident of the State of Florida since-____-__ -......
-----January_________-____-________-___-, 18 61, snd I reside at.-_____ 140* _ Delaware _A~~____________-_____-- --
-- (8treet sad Number) -- ---
Fort Pis r4 a St • ~o i • _ County, Florida,
----------------------------- -----------
-- (cxt,)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in
the State of Florida.
(Insert bare an7 pertinent facts. such as ssb osefl ~~nn~ of lwme.or~r~lln9nishment of emplu7ment tt
termer domicile. na+oral of tamil7 to new dorm e. p
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I FURTHER CERTIFY that I will register at my Iocal address when the registration hooka reopen,
and comply with all other requirements of a Legal rceident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domicile, and I intend to remain
St . Lucie __County, Florida,
- ---------------------------
~-----F~~- --~---@~~ e_--------------------- ------------------------- --
-------------
permanently. .,b'-"5~-~ _----------------------------------
------ (Name)
John Skeena
- -- (Address)
Sworn to and aubacrib@d before n4e this____--~e~iy of
•,.-..
:-
Feb~uaT-l[----------~--- '~ - ~ " - - .A. D. 19 al_-.
~ ~ ~.
-- ~.. - imsie
My Commission ~• _~ g-~ ~ d~
• . ~~~ filed with Clerk Cirenk Court. sad duplicate with Tax Assessor)
(To be executed iA dt~yl~eab sad ss{~inal
.. , , t c't n. Fta.