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~ Declaration at Domlcile ~rnd ~itizenship j
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TO TNE STATE AND COUNTY TAX A5SES50R, ~
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51. IUCIE COUNTY, FLORIDA: ~
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This is my declaration of Domicile and Citizenship in the State of Fiorida that I am filing this day in atcordante and ~
in conformity with Chapter 222, Section 222,17, Florida Statutes.
Conn~
Wallin ford ~~~,Z
I was formerly a legal resi~ent of . . _ . _ _ _ g___ _ _ _ .
(City) ($tate)
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and 1 resided at ~0 $1~MIin_CilCle_ _ _ However I have changed my domic,ile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since 17tb_ _ _ day of
_ `~~1~_----_-__------, 19_bs, and I reside at -R_Ti _2--Boac__2765-B Lakewood Park~__~_
(Street and Number)
fOitT PIERCE, SAtNT LUCIE COUNTY, FL~RIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the 5tate 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.}
N~~r ponicle
I~L'E7I~ A'NA; R~C{?RDED
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I FURTHER ~ERTIFY that I will comply with all other requirements of a legal resident of this State. ~
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i FURTHFR CERTIFY that I have r.o intention to return to my former domi~ile, and i intend to remain in FORT `
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PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
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...,M ,~~hn ,j_.._._Watson_ ,
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• , ;Name) ;
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2nd Septemtcr 6S i
Swom ta and subscribed before me this day of - , 19 . ~
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ROGER PQITRAS - f
CLERK CIRCUIT COURT Notary Pubfic ~
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By ~ ~ ,~,~,i.z-•'~ ~ D.C. My Commissian expires _ ,
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^ (1'o be execut~d in duplitite and original fiied witi~ Clerk Circuit Cavrf, snd dapliut~ with Tax AssKSOr.)
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