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~ Dsclaration ot Domlcile and ~Itizenship ~ "a-
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~ TO THE STATE AND COUNTY TAX ASSESSOR, 13~t7~7~p ;
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~ S'f. IUCiE COl1NTY, FIORIDA:
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~ This is my declaration of Domicile and Citixenship in the 5tate of Florida that 1 am fiiing this day in sct~rdanoe and ~
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j in corrfdrmity with Chapter 222, Sect+an 22?.17, Florida Statutts.
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1 was farmerly a legal resident of H~w B!I g A1CM? Yvrk
(City) (5fate)
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' and I resided at _-----J1.lY-tS--~f Si~-~+ pad~.~.Rt However 1 have chsnyed my domiCile
(Street and Number)
to and am ar?d have bcen a bona fide resident of the State of Florida since _._________-~'at~~_ day of
, 19__~~ and 1 reside at Oru~a~ A~?t• `
~ (Street and Number? ~
FORT MUtCE, St INT LUCl6 GOUNTY, RORlDA
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and this statement is to be taken as my declaration of citizenship, act~al legal resid~nce a~d domicile in the Stata af Horida.
(Insert hEre any pertinent facts, such as saie of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of hame, etc.)
~?ntering children in school in the ~~all .
$stabl.ishing residency F~
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: . . ss AUG 9 ~1 !0 : ;
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: =~J ; :r - R~~ER ~`'~?~r ~
• , ST ~UC E}~~, ~ERK
' ~ ~ _ FLORf 4UNTY~
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: I FURTHER CER7'IFY that I will comply with all other rcquirerr~ents of a leqal resident of this State.
' t FURTHER CEitTIFY that 1 have no intention to return ta my former domic.ile, and I intend to remain in FORT
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' PIER~E, SAIN7 LUCIE COUNTY, FLO~CIDA, permaner.t!y.
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~ ~i, , _ (Name) -
~ ~ - ~ _ Blizabeth T. Prsnge ;
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Sworn''to and subscribed 5efore me this - 9t~ day of t , 19~~.. ;
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F
ROGER POltRAS ~
CIRCUIT URT Notary Public ~
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~ B D.C. My Commission expiras
Ro b. •x.eu~+d in dupticat~ and ori~i~+al fif+d wiH~ CM.k Cir~cuit Court, and duplie~ Mrith Ta: As~or.)
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