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Declaration ot Domicile and Citizenship ~
70 THE STATE AND COUNTY TAX AS5ES50R, ~J~~~~
51. tUCIE COUN7Y, FLORIDA:
This is my declaraTion of OQmicile and Citizenship in the State of Fforida that I am filir.g this day in accordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of/" _ - ~
(City~ (State)
and I resided at ~y~~"'~ However I have changed my domiCile
(Street and Numberl ~
to and am and have been a bona fide resident of the State of Florida since _ day of
~ / L l 9 , Ci ~,/~IG6`sLs-tat- ~
L , .,nd i reside at _ •
~ (Street and Number)
:
FOi~T PIERCE, SAIN? LUClE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, attual legai residente and domicile in the State of Florida.
(Insert here a:~y pertinent facts, such as saie of property or business, or relinGuishment of employment
at former domicile, removai of family to new domicile, p~rchase of home, eic.)
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~
~ ~ .~.~.3 i~3'76
FILED AND REC RDEO
~h.~ ' BOOK
, rn`
, . ',V- . - 'fi5 MI~Y 2 0 AM 10 : 0 ~
~ . _ .~,,,t~~~~~ .
. • - ~ - . ROGE~ r~G~ ~ Ras. CL~RK
ST. LUCIE COllivTY,
~ - ~ , FI.ORiDA
.
I FURT~IER CERTIFY that 1 vvii! comp!y with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that ! have no intention to return to my former ~omiC~le, and I intend to remain in FCRT
PIERC~, SAINT LUCIE COUNTY, FLORIDA, permanently.
_ ~ ~ nl n ~ ''i~ 'k _ /~~~~r~L .l1Y._C.C6C .
' _ ' ~ '~S~ ` (Name)
- . ; .
, . .
~ • • _ _ - -
~ - • (Address)
y ' Y~. .
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~ Swom to and sunscribed before me this _ daY of -
~
ROGEit POlTRA,S
RK CIRCUIT URT Notary Public
g_ U.C. My Commission expires _ -
~ (To be executed in duplicate and original filed vvi4h Cie~k Circuit Court, and dupliate with 1'ax Assessor.)
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