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' Deciaration of Domicile and Citizenship
.138~~~ 3 .
YO THE STATE AND COUNTY TAX ASSES50R,
51. LUCIE CQUNTY, FLORIDA: ~
This is my declaration of ~omicile and Citizenship in the State of Florida that 1 am filing this day in accordante and
in tanformity with Chapter ?22, Section 222.17, Florida Statutes.
I was formerly a lega) resident of _ _~1niStOl~____~ _ -
(City) (5tate)
and I resided at _~~4T ~~l~iZd~-. --~Y.- - ~ However I have changed my domicile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since _~.Sth__ day of
______~__._.~up~.'-- ?9-----6~nd I reside at ___2LQ5 SO Iad Rv Dz
(Street and Number)
FORT PIERGE, SAINT LUCIE COUNTY, FLORIDA
and ihis statement is to be taken as my decfaration of citizenship, actuai legal iesidence and domicile in ihe State of Florida.
(Insert here any pertinent facts, such as sale of properiy or business, or relinquishment of employment
at former domicile, removal of farr~ily to new domicile, purchase of home, etc.)
Enterireg children in sL~ool
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1~~~~~('~ • A. . .
J c~ERK
RocER i=(:.~"i n: s. = -
ST.. L' y.!?C.iE G.QIlN i~Y:.. r- _ F
FLQ~lIQA - . y-
~
,
. . . _ . , .
I FUR7HER CERTIFY that I will comply with all other requirements of a legal resident of this State.
I FURTNER CERTIFY that ~ have no intention to return to my former domi~ii~, and I intend so remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
: . . (Name)
" ~q/ AlYin S ~u11en
# - ' (Address)--
~ ,
~ Sworn to fnc~ subscribed befare me This ____16th _ day of ~~st , 19 ~5 •
ROGER PQITRAS - -
K CIRCUIT OURT Notary i'ublic
~ mi ' n x ires _
gy D.C. My Com ssio e p
-(To b~ ~xecuted in dupiicate and oriqinal ~iled w' {e Grcuit Cou~f, and duplicate with Tax Ass~ssor.)
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