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Oeciaratlon o! Domlcile and Citizenahlp .
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TO THE STATE AND COUNTY TAX ASSESSOR,
ST. WCIE COUNTY, FIORIDA: , '
This is my declantio~ of Oomicils a~d Citizenihip i~ ths State of Ftortd~ that 1 am fiUr+q thi~ day in aaada~os end
In confonnlry with Chapter 2Z2, Ssction 2~2.1 . Florida Statutes. ~ i
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I wa: formsrly a laqsl resident of _
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~nd 1 rosided at - However 1 have chenqsd n?y domidle
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(St~eet and Numbsr)
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to a~d a~ and hsve besn a bo~ns fide ~ident of the Stats of Florida sinos day of
1 , and 1 rosids a1 ~ ,
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~ fORT f1~CE, SAtNT tUC1E COUNTY~ RORIDA
and this statement is to be taken as my declsration of citizenship, actual legal residena end domicite in fhe Staro of Florida: . ~
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pnsert here any pe~tinent fects, such as sale of propeny or busi~ess, or ralinquishment of emplo~ymsnt ~
at formsr domklls, removal of family to new damicile, pu~chase af twme, etc.)
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~ I FUR'THER CERTIFY that 1 will ~p~Y w~
~ all other roquirements of a legal rosidant of thi: State. ~
1 RIRTHER CERTIFY that ! have no intention to rofum to my former domivle, and 1 inbnd ta remain in FORT ~
~ PIERCE, SAINT LUCIE COUIVTIf, FLORIDA, pe~rmanently. ~
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~ `Sworn to and wbsuibed before me this day of • 1~
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' ROG~ ~OITRAS
CIR COt~RT • Notary Pubik -
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~ 8y D.C. ~My•CommEuion expiros
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- (Te b~ ~oc~cvhd iw deipqcsh and o~iyind fll~d wirb CM~Ic Cirarit CouR, and duplkNi ~ ~oi u~e~a
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