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' TO TME STATE M10 C'OUNTY TAX A~SSESSOR,
, ST. UtC1E COUNTIf. FLORIOA:
I • Thit Is m~? d~d~~atbn of Oomidl~ and Citit~nshlp 1~ th~ St~t~ of Haid~ that 1 am filinq thl~ d~y i~ aooorda~a a~d
In confo~mi~y with dNptw 2Z~. S~ctio~ 24~.17. Norida St~h?ta. . .
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, 1 was form~?Ir a Ipal ~Id~?t of ~ ~~e Worth ' . Plosida
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' and I ~uid~d at 3721 AL?as St•___ I~IoMr~vK 1 haw cM~q~d my domidl~
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b and wn Md haw bNn • bona fid~ ~id~nt of th~ Stab of Florida ~i~+o~ 10 -~Y °f
~ . ~to~= 104 Roselya 1?~e.
- - 19 64 and ~ nsid~ a
(5tn~t a~d Nurr~r)
~ lpRT NERCR, SAINT LUCIE OOYI~11'Y. RORIOA .
and this stat~nsnt is to b~ tak~n as my dsdu~tion of dti~nship, adual Ic~l r~tid~no~ and domldl~ in th~ StaN of Florida.
' qnse~t Mn sny pertinent facts.-wd~ as sale of property or busi~s, or rolinquisfim~nt of ~mp.b~?m~nt
; at formsr domidls, removal of family b new domid{e, purchass af hon~, ~
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• Bstab~ishing sesidence [N aJR~CORD~p
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~ 1 RIRTHER G~TIFY thd I will comply wiTh all alhw niquin~rwNS of a ipal n~W~M of thit ShN.
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€ 1 fURTHER CERTIFY that 1 h~ve rw In»ntion to retum b my formsr domkiit, and 1 iM~nd to rNr~ain in FORT
P19~CE. SAINT WCIE COUNTY, FLORIDA„ permanenNy. .
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