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D~rClaratian af Dore~icile and Chis~n~hip ~ ~
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TO THI~ STATE AND COUNTY TAX ASSE550R, ~,3,.74~~ ,
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. SI. lUC1E COt1NTY, FIORIDA: i
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Thia is my declaration of Domicile and Citizenship in the State af Florida that I em filing this day i~ sttordance and s
~ in conformity with Chapter 222, Section 222.17', Florida 5tatutes. ~
~ ~ Me¦ bis Tena.
~ I was forme~ly e le9al resident c,f
~ • (City) (5ta») -
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ar~d I resid~ed at __-~B~IOrth Idlerl~lde Hawever 1 have changed my domiCile .
(Stroet and Number)
` b and am and have bcen a bona fide resident of the State of Florida since 9t~________~___- r~ay of
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A ril 6S ?12 Beich Conrt ~
, 19___, and I reside at
(Street and Number)
~ fORT NERCE, SAINT LtlCIE COUNTY, ~ORIDA - :
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and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State af Fiorida. ,
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~ (tnsert here a~y pertin~nt facts, suth as sale of properiy or business, or relinquishment of employment
~ at former domicile, removal of famity to new domicile, purchase of home, etc.)
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: Bst~biiahing resideACy ` -
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~ BnteriAg children is publ#~~ achool in the fall ,
° ~ ~N tLED AND RECO~O~rp
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; _ ROGER P011'RAS. CLERK •
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• , ST.
N ,r,j:, LUCIE COUNTY,
G FLORIDA
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1 FURTHER CERTIFY that I will comply with all other requireme~nts of a ieqel resident Qf this 5tate.
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~ I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and 1 intend to remacn in FORT
i PIERCE, SAtNT LUC~E COUNTY, FLORIDA, permanently.
' C_~
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` ' ; (Name)
- ~ - . ~ PtBBY Walter B~rg
. : ~ 7 : - Ol'I A~ Bl,~,g/ ~
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'~wort1~ to and subscribed before me this al _ day af Jdl _ .
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R ER POITRAS ~
¢ K CIRCi11T C URT Notary Public
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~ 6~ D.C. ~My Commission expirea ~x
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, ~ (To t?~ exscuMid in duplicri~ and o?iyinal fil~d with Clerk Circuef Court, and dupliasts wifh T~x A~or.)
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