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~.;\ ' 59 PU 654 '
01 bomicile and Citizen8hip
ST. '. lICI( Cl'''~Y, rL~.
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Declaration
TO THE STATE AND COUNTY TAX ASSESSOR,
:iT, LUCIE COUNTY. FLORIDA:
This is my declaration of Domicile and Citlzp.nllhlp in the State of Florida that I am filing this day in aCC'Ortlanct'
an:l in conform:ty with Chapter 212, Section 222,17, Florida Statutes.
GRIFP'IB
I was formerly a legal re3ident of
GEORGIA
[City)
1317 West Poplar Street
[Street 8!ld Numberl
to and am and have been a bona fide resident of the State Qf Florida since
State
....
and I rM!ded at
. However, I have changed my domicile
. .
1st
day of
July
62 Parkway Grove Est.
19_, --. and I /'elide at
[Sh'eet and N\lmber)
FORT PIERCE, SAINT LUCIE COUNTY. FLORIDA,
and this statement is to be taken as my declaration of c1tizeruh ip. actual legal residence an~l domicilE' in the State oC Florida,
[Insert here any pertine:lt tach, such a3 s3le of property or busines3. or relinquishment of employment
at former domicile. removal oC family to new domicile pelrehase oC home, etc.]
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Applying for homestead
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S:. Lucie'
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I FURTHER CERTIFY that I will register at my Local addres5 when the registration b:Joks reopen, 8:1d comply
with all other requirements of a legal resident oC this St!lte.
I FURTHER CERTIFY that I have no intention to return
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
in
[Address]
30th
Sworn to and subscribed before me this__
.IlII.aroh
63
19__
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" :....,., ' '., 0 " Notary Public
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D,C, ~_)~::. My Co~s{o:g; ~xPires_
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[To be t'-XlX'uun In duplicate and orlgin~ flied with .Olerkql~~,.Oourt, and duplicate with Tax As~es30rl
RaGE POITRAS
CLERK c~