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~ D~claratta~ of Domici!• and Citi~enship ~
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TO THE SYATE AND CUUNTY TAX ASSESSQR, y
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~ Sl. IUCIE COUNTY, FIORI~A: ;
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; This is my declaration of Oomicile and Citizenship in the State of ~lorida that I am filing this day in accordence sr~d ~
# in rnnfarmity with Chapter 222, Section ~22.17, Florida Statutes. ~
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Bsaird R a ids lii c hi sn j
1 was formerly a lesgal resident of .~W____._. P' $ -
(City? (State) z
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and i r-s~ded ar 10+19 _34th ST~~~__~ ~V1evar I have chanqed my domit,ile i
(Street anti Number)
b and am and have been a bona fide resident of the State af Florida since .____18t$ _ ~ day of ;
, 19
b~, and I reside at ~21$ ~O. llt# StL t
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(Street and Number)
FORT PlERCE, SAlNT IUCiE tOUNT7, FtOitiDA ,
and this statement is to be taken as my dcctaration of citi=enship, actual legal residence and domitile in the Stet~e of Florida.
(tnsert here any ~sertinent facts, sucF~ as sale of property or business, or relinquishment of employment
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at former domicite, removal of family to new domicile, purchase of hame, ~tcJ
Batexing Childrea in School
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FILED AND PtECOROED
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~GER PCiITF;AS. CL~RK ~ '~~`?r•~+: •
~ R~ST. LUCIE COUNTY.
FLORIDA
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; ! FURtHER CERTtFY that t will comply with afl other requirements of a lega! res~denr nf rhis Stete.
; I~URTHER C~R71FY that I have no intention to retum tc~ my former domi~ite, and t intend ta remain in FORT
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~ PIERCF, SA1NT LllCIE COUNTY, FLOR{DA, permanently.
' G~rtrnde I~lozelle Jqergen
` (Name)
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Sworn to and subscribed before me this ~~fi~day of ~ , 19~~ ~
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~R,,~~iE~; ~,!'OI~RAS _
a 1'~COUitt Notary. Publit
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' By ' D.C. My Commission expires ~
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•`~'o' lr~.~;±~il~d`i~ duplicah and orisi~sl fi{~d with ClKlc Circuit Cn+rirt, and duplicate with Tax A~or.)
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