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Declaration ot Domiciie and Cltizensh~p t t~~ j f~~!
1
TO THE 5TATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUN7Y, FIORIDA:
This is my declaraTi~n of Domicile and Citizenship in the State of Florida that i am filing this day in accordante and
in conformity with Chapter 722, Section 222.17, Florida Statutes.
I was formerly a legal resident of Chicago Illfnois
(City) (State)
2856 West palmer
and 1 resided at _ . _ _ However 1 have changed my domi~ile
{St~eet and Number)
to and am and have been a bona fide resident of the State of Florida since _ 1 day ot
April 65 105 Prima Ynsta , Port St.Lucae
- - - - - 19-- and I reside at . - - _ - - _
(Street and Number}
FORT PtERCE, SAINT LUCiE COlJNTY, FLORiDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State 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, purchase of home, etc.)
F~tES ANO RECe DEC7
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90~K
Establishia~ residen~,e i~~ y r
.
12 ~ ~Iz
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-
ROGER P~irRaS CLERK ~
~T. LUCrE CatJNyY
FtAR#~A "
- .
:
I FURTHER CERTIFY thai I will comply with all other requirements of a legal resident of ihis S~t~ter,
. `
" - , .
I~URTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to~~~n7ain ~iii .~QR7.~ ~
PIERCE, SAINT i.UCIE COUNTY, FLORI~A, permanent!y.
U-~~- - ~
(Na e)
1 '
• . . Peter Jorgensen -
y~y` 3, r-
' - (Address)
. ~
. . ~ ,
w
v 65
Sworn ~o+af~s4bscribed betore me this _______4_-___ day of Ctpber , 19 .
,
~ , • _
j_: _;,i~,.:=. -
ROt3~it PORRAS
CLERK l11T C~URfi Notary Public
By , D.C. My Cammission expires
(To be execuled in duplicate and originsl fiiled with tlerk Circuif C.purt, and duplitate with Tax Asserssor.)
- :P2~ . 55