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~ . ~ 60 ~., i 676
Declaration of "Domicile' ~~d Citizenship
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TO THE STATE A;>':D COUr\TY TAX ASSESSOR.
,,1', u:cn: COl';>.:TY, FLOlUDA:
This is my declarati)n of Domicile and Citizenship in the Stnte of Flordn Ihat' I am tiling this day in aC\.'Ortlancv
a:1d in conformity with Chapter :222, Section 222.17, Florida Statutes.
I was formerly a legal re3ident of ~~-
[City]
ALA.
State
and I resided at
1102 Seminole DriT8
[Street and Number)
.____ __~___ 'However, I have changed my donlicile
to and am and have been a bona tide resident of the State of Florida since ____ 14th
day of
April
6~ ' ~24 So 11th St
19_ ~ and I reside &t ----
[Street and N\l.mberl
FORT PIERCE, SAI;>.:T LUCIE COUNTY, FLORIDA,
ar,d this statement is to be taken as my declaration of cilizeruhip, actual legal residence an:! domicile in the State of 'Florida,
[[n,~rt here any pertine:lt facts, su:'h as s11(' of propelty or business, or relinquishme:lt of ~mplG/ment
at former d0:11icile, rel\lo\'al of family to new domi cile purchase of home, etc.]
Entering Peggy Neil Sasser in the 2nd grade
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I FURTHER CERTIFY that I will register at my local address when the registration b~oks reopen, and comply
with 1111 other reluirements of a legal resident of this State,
I FCnTHEH CERTIFY that I have no htention to return to my former domicile, and I intend to remain in
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanent]>'.
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Sv.'orn to and subscribed before me this
15th
ja '-Of ,,' '. _.,April
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. ' Notary Public
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fp POITRAS
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D.C, _J ~ My Commissioo eXpires
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[To be e.xll<'uted In dup!l('ate and original tiled with CIl!rk <:-'trctH( court, and dupllcl\te with Tax Assessorl