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~t~l~ratio~ of Donricile and Citlsen~hip ~ ~
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TO THE STATE AND COUNI'1' TAX AS5E550R,
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Sl. LUCIE COUNTY, FIORIDA: ~~g ~
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This is my detlarotion of pomicile and Citizenship in the 5tate of Fforide that I am filirg this day in attordance and ~ '
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in conformity with Chapter 222, Settion 222.17, Florida Statutes. ~ c
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I was formerly a legai resident of ______He2~~~~ ~eaeh California ;
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Ciry) (Stab) -
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' . _ However I have changed my domiCile
and I resided at __~41.____Stl~
P18Ce :
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. ro end am end have been a bona fide resident of the State of Flwida since ~?th dey of '
Tamporary
~#,,emhez-_-~, 196.~__, and I reside at ~_~idgehavell xd
(Street and Number)
FORT MERCE, SAINT WCIE COUNTY, RORIDA ~
and this staiement is io be takan as my deciaration of citizenship, actual legal residence and domicile in the Steta 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, purchese of home, elcJ
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~ntering child in school ~OOK ~
,,:,~~n~t~.~,;~r~,. ( Betey ~eed ) ~65 $F~ [
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I FURTNER CERTIFY thet I will comply with all other requirements of a legal rasident of this State.
' I fURYHER CERTIFY that I have no inlention to return to my former domiGle, and I intend to remain in FORT ~
PIERCE, SAINT Li~1~lE COUNTY, FLORIDA, permanently.
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~ ;,~~.n,-~`'II k `~~~'C.C.•C.t.+~/ ~
, ' . (Name) ~
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, ~ Colleen .:~i.nebau$h ~
• . . "7w.~'
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Swom to and subscribed before me this day of September , ~q 65 , I
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~ ~ R04ER POITRAS - ~
~ K CIRCUIT URT Notary Public
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By D.C. My Commission expires
(To I~ ~zMCVbd in dupliuh md oripirul filed with Cl~erk Ci~cu~t Courf, ~nd du~liuts wNh T~x A~tor.)
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