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Declaration of Domicile and Citizenship
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TO THF STATE AND COUNTY TAXASSESSOR'~:~~'l~~.I.E..E:.~N!,Y_:..r.~^:.
ST. LUCIE COUNTY, FLORIDA:
~131764.
This is my declaration of DomicUe and Citlzenahip in the Stahl or Florida thal I am tillna this day in accordance
and In conformity with Chapter 222, Sadlon 222.17, Florida Slntutes.
I was formerly a leaal resident of
',;e .'t Hartl'oru
(City]
Conn
State
17 3unri se lUll 1.)1'1 ve
(Street and Number]
to and am and have been a bona fido resident of the State of
"-
. However. I have changed my domicile
and I resided at
Florida lin~
::Oth
Po r't ::>t .luc1 e day of
420 PriQo Vista Blvd.
[Street and N\lIllber]
:.ec c".bel'
19...2.L and I relid~ at
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA,
and this statement is to be taken as my declaration of cltLzeruh ip, actual legal residence and domicile in the State of Florida.
[Insert here any pertinent facts. Iuch as aale of property or bwlness, or relinquishment of employment
at former domicile, removal of family to new dom! clle purchase of home, etc.]
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I FURTHER CERTIFY that I will register at my local address when the registration b:;oks reopen, and comply
with aU other requirements of a legal resident of this State.
I FURTHER CERTIFY that I haye no intention to return to my former domicile, and I intend to remain in
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA,
permanently, ~. '9/' /?~
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P H t.tiNSnrne]
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[Address]
Gth
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Sworn to and subscribed before me this--
2~OITP~
EPK C1RCu~couRr
3y ~<J(J &~d
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Notary Public
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D.C. 1..':' ~..M)' :<:omrruss~ expire!
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iTo be executed In dupUeate and orlrlnaJ fUed wlUl (:ll~' ct~t oourt, and dupUcate with Tax Asse!lSor]
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