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Declaration ot Dom~ciie and Citi:enship
TO THE S~ATE AND COUNTY TAX ASSE.SSOR,
ST. UJCIE COUNTY. FIORIDI~
This it my decla~ation of Domicil~ and Citi~nship in ths Stst~ of Hortda that I am fflirp thb d~y in aooordana and
tn oonfcrmity with Chapts? 42Z, Sectbn 222.17. Hori~a Stah~ta. .
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I was form~ly a Ipa) rosid~t of ~~Q~ ~ _ O~
KiN) (S~,ro)
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~~d 1 rotid~d at ~ How~vK 1 hav~ chanqsd my domidl~
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b and am a~d have be~n a bons fids ~id~nt of the Stats of flaida si~os D day of
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~ (Stroet and NumbK)
I~ORT M~~'~, SAINf Lt~C1E COUNTY, RORIDA ~ ~~JJ' ~
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snd this slatsn~t Is to be taken a: my declarstia? of ciNzs~+ship, actual legal residanoe and cbmidle i~ th~ Sta» of Horid~. ~
pnsert here any ps~tinsnt fact:, such as ~le of properfy or bu:inss:, or rolinqui~msnt of employmsM f
at former domkile, renwval of family to nsw domidle, purchase of tame, etc.) ~
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~ `,y~''~~~. ROGER POtTRAS. CLERK .
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. ~ E co • St. LUCIE COUNTr. FLORIDA
1 FURTHER CERTlFY that I wfil co~npiy wHh
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all oti~ requirements of a tegat resident of this State: ~ '
~ f FURTHER CERTIFY thet I havs no intention to retum to my formsr domic~le, and I intend to remsin in FORT
PIERCE, S,pINT LUCIE COUNTY, FLORtDA, pem~anentiy.
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Sworn to and b~d bsfor this ~
, wbscri ~ m. day of . 19~
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+ ROG~ rO1TR11S ~
` G COURT Notary Publk
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i d~l j D.~ ' My Commiuion expires
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? R~ b~ ~oc~o~Nd i~ dnpNe~aa aed aiaiw~l Rl~d wi1i~ Cl~c Ciraih C~w1, a~d drpliab~wilh Tavc A~~a
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