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Oeclaration ot Domicile and Citizanship
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TO THE STAI'E AND COUtVTY TAX ASSESSOR, i`-~`~
51. LUCIE COUNTY, FLORIDA~
' This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accnrdance and
in conformity w+th Chapter 222, 5ection 222.17, ~lorida Statutes.
Rossville _G~
I was formerly a legal resident of _ . . _ _
(City) (State)
and 1 resided at _ 977 Gr~E'IIlllll Dr1Y~ However I have changed my domiSile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since _~rd_ day af
_ ___oCtobeY _ _ _ ~q_ 6.5 , and 1 reside at 443_P~tktitav
• (Street and Number)
PORT PIERCE, SAtNT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residente and domicile in the State of Florida.
{Insert here any pertinent facts, such as sale of property or business, or relint~uishment of employment
at former dpmicile, removal of family to new domicile, purchase of home; etc.)
TO PLACE CHILD IN SCHOOL
FI ~~ft~RDEO
;e ROOK
Milton Scott Phillips 5yrs. C~
'65 (l~:T ~~hl 9 : I 8
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ROGER rU~ i f~,~;S, CLERK
ST. LUCIE COUNTY.
FLORtDA
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I FURTHER CERTIFY that f wifl comply with al) other requirements of a legai resident•;qf'~3~S~~a{e;', -
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I FURTHER CERTIFY that ! have no ;ntention to return to my former d~mi~ile, and i intend to remain in FOR7
PIERCE, SAINT LUCIE COUNTY, fLORIDA, permanent!y.
,
7?~~_--7~~?~~~' ~ '
(iVame) M~S. . Lo Phi111ps
~ __603 Parkway, Ft, Pierce, ~la~
(Address)
Sworn to and subscribed 6efore me this ~y-~~ath day of ~__OC~ObL'7' ____i, ~q~~,
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ROGER POITRAS - ~ - - -
CLERK CIRCiJIT URt = ' • ? ' - ~ ~ ~ Notary Public
g ` ~ ` D.C My Commission expires _ ~
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(Ta be sxecuted in duplicate ant! arigina ' with Clerk Circuit Co~rt, snd duplicate with Tax Assessor.)
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