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Declaration ~t Domicile and Citizenship .
TO 7HE STATE ANq COUNTY TAX ASSESSOR, .t ~E)~~>`~
1
si ~uc~E couNr~•, F~o~i~a
This is my declaration of Uomitile anc! C,tizensh~p in the State of Fiorida that I am filing this day in accordance and
in conformiry with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of Brookiyn _ New YOI'k
(C~ty) (State)
and t resided at . 196 Cllllt017 Ai?eI11t@ However I have changed my c~omiGile
(SYr~et an~ Number)
t~ and am and have been a bona fide resident of the State of florida since IS _ day of
March 65 1405 Pon~e De L+eon Prado
- , 19_ , and I reside at . .
(Street ~nd Number)
fORT PIERCE, SAIN7 LUCiE COUNTY, FLORIDA
and this statement is to be faken as my declaration of citizenship, actual legal residence a~d domicile in the State of Florida.
(Insert here any Fertinent facts, such as sale of property nr business, or relinquishment of emplayment
at forrner domicile, removal af family to new domicile, purchase of home, etc.)
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~stablishing residence fss
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I FURTHER CERTIFY that I will comply with al~ other requirements of a lec~al residert a~.~his;'S~bt~;~~~~~,~~ -
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t F;iRTHER CERTIFY fhat I fzave no ir~tention ta returr~ to my fo~mer domi~il~nd 1 intend to r~main in FORT
Gr~~ ~ ~
PIERC~, SAIN7 LUCIE COUNTY, FLORIDA, permar,ently ~J ,~+n.¢.+.~,(,`
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4 Sworn to ~nci substr~bed before me ihis __-_.15_ _ day of -_---__--.~~?1_1E _ , 19 b~
ROGER PAiYRAS
RK CIR COURT Notary Public
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By ----_-~`_~i~_'~-_ - D.C. My Commission expires ~
(To be executed in duplicate and original fifed with Cteric Grcuit Court, at~d dupiiute wi~h Tsx Assessor.)
~~~`~r:i~t~ . 33fi