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I u TilE STAn: AND COUNTY TAX ASSESSOR,
:-;'1', l.lcn: COl':'.ny, FLORIDA;
Thl~ is illY dedaration of Domicile and Citiz:enship in the <;tate of \o'lorida that I am tiling this day in accordt.nce
!llId in "Jlnformity with Challter 222. Section 222,17. Florida Statutes.
I wa3 fornll'rly a legal resident of
~
(City)
State
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,.', i I rl"'idl'd at
day of
-u4J,
my domicile
However. I have changed
/o-/R;-
( S, reet and NumbH)
t, "n,1 illll and hllve ueen a
resident of the Stnte of Florida since
---- 74
j!}~~ . and I reside at.!..2?J?
( Stee
FVHT PIERCE. SAI:-oIT LUCIE COUNTY, FLORIDA,
a,1 Ihi, ,1at.'IllI'n~ is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(I n'ed here any pertinent facts, such as sale of property or business, or relinquishment of employment
il~ for'ner domicile. removal of family to new domicle, purchase of home, etc.)
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ISS1 HP,r\ 19 PM 4: {~6
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I !,TI:TlIEI{ CERTIFY that I will register at my local addres~ when the registration books reopen. and comply
'.\','" "I! ' ltll'r requirelllents of a legal resident of this State.
I Fl7llTIIER ('ERTlF\ that I have no intention to return to my former domicile, and I intend to remain in
j'()llT I'II-:nn:, :;,\I:-':T LUCIE COU:-lTY. FLORIDA,
perma nently. J7 ~ I J I
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(Address)
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b,i,rc me this
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, 19
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:-'0)' ,'-1 lIJ~11
day of
Ily
['OITRAS
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Notary Public
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) ~:,o.C. ,My Commission expires
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filed "ltb.,.~ " Ctrcuit Court, and duplicate with Tax A.85e85or)
(T'I he cXI'("uLd in duplhate and oriRin.1