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Declaration
Oi.\, 60 llCf 342
of Oomicile and Citizenship
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TO Till: STATE AND COUNTY TAX ASSF:SSOn.,
->T, U'('ll: COt:0:TY, FLORIDA:
This is n:y declaratien at Domicile :lnd Citizenship in the State ot Florid<'l th<'lt I am tiling this day in accordance
<'I:ld in cdntollnity with Chapter :lZ2, Section 2"l2, 17, Florida Statutes.
I Wi,'; tomlerly a legal resident of
Salem
[City]
and I resided <'It_
Rt
5
Ind.
State
(Street and Number]
"-- , lIowe\'er, I ha\'e changed my domicile
to <'Ind am and ha\'e bren a bona !ide resident of the State of Florida since ___,__let
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19__6:3" and I reside at
FOIlT PIEnCE, SAI:\'T LUCIE COUNTY, FLORIDA,
day of
Boa 5600 So. :red. Hi-way
[Street and Nwnber]
:If~d this ,!:.ti:::~'I,t is t'J be t:\k'cn as my declaration ot citiwnsh ip, actual legal re3!denl'e an'l domicile in the State of Florida,
I !:',,('rt b::'~ :l!1Y p~rtine:H (:1'.t>, suC'h :., s31~ ot preperty or business, or reli::f]lIishr.lcnt of employment
:.1 fOrfl}('r do!niC'ile, r(;:l1o\'al of t:lmil,' tn I:ew domi rIle p' :rc!nse of home, etc,]
Entering Vitti Lynn Stewart in the 2nd grade
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F.U~::' Y:J rEee 1GEC
1" Official Rec(}fd-'GJK
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I FUftTHEn CEHTIFY that I will register at my local address, when the rer:istration b:oks reopen, and comply
with all other re'!uiremel,ts oi a le~al resident o! this State,
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA, pern:anently.
1 Fl'HTIrf'~ CERTIFY that I ha\"(~ no intention to return to my former domicile, and I intend to remain in
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/. [Name]
Sworn to and subscribed before me this-
8th --jay of _~ril
r:OG!A POITRM,
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.
[Address]
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, \;)~~"\c. u'i:..,~~,-' Notary Public
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D'f. :' .- --,My ,~~~ioJl expires
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--[TO be l',,,:~t~~~n dllP~I('~:~:;orlgln~ ~IM -W~~tk{~':~~r~, nnd duplicate with Tax AssessOi"]
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