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Declaration ot Don~iCile and Citiz~nship
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TO THE STATE ANO COUNTY TAX ASSES50R, '
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~ Sl. LUCIE COUNTY, FLORIDA:
3 This is my detlaration of Domicile and Citizenship in the State of Florida that I am filing this dey in atcordance and f
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- in conformiry with Chapter 222, Section 222.17, Florida Statutes.
, I was fo~merly a legal resident of _--B~~.~~4n - - - . -~GS~-~ - .
(CitY) (5taM)
and I resided at ______R4Lttt 2 However I have changed my domitJ~c
Y (Street and Number)
to end am and have been a bona fide resident of the State of Florida since _ -~2___-- day of
July 65 407 Avenue F -
- - - - , 19----, and I reside at -
(Street and Number)
FORT PIERCE, SAINT LUClE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purthase of home, etc.)
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Er~tering Son in school 1'`-"--_.~O~Q ~D
, ~6S AUG °~K
Bstablesbirag residea~ce y
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1 FURTHER CER71~Y that I will comply with all other requirements af a legal resident of this~,~~t~,~" , - ~
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I FURTNER CERTIFY that I have no intention to return to my former domi~ile, and I interd to ~r~maif~: in ~~ORT
PIERCE, SAIt~IT LUCIE COUNTY, FLdRIDA, permanently.
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, . (Name} ~
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` filaint Bailey
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{I'j ~3y~orS+~'~o dnd subscribed befare me this '4 day of ~~t7St .,g--~,~
ROdER POITRAS -
K GIR COUR7 Notary Public
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gy _ U.C. My Commission expires _
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(To bs exsctit~i in duplicats and o~~ginal ~led wit4~ Clsrk Cirsuit Court, and duplicah wifh Tax Ass~ssor.)
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