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Declaration ot Don~icila and Citizenship '
TO THE STATE AND COUNTY TAX ASSESSOR,
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•Sl. lUC1E COUNTY, FIORiDA: ~ '
This is my decleration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and ~
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in conformity with Chapter 222, Section 222.17, Florida Statutes. ;
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Raleigh North Carolina (
I was formerly a (egal resident of - - t
(Ciry) (Stab) ~ ;
Route a
and t resided at - - ~ _ - - - . However I have changed my domic.ile ~ ~
(Street and Number}
to and am and have been a bana fide resident of the State of Florida since 4 day of ~
- ~Rou~e 3- ,
O~ctober 65 Minute Irlaid Groves
- 19~__, and I reside at - !
~ (Street and Number) ~ ~ ~
~ORT PIERCE, SAINT LUGIE GOUNTIf, FLORtDA ~
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and lhis statement is to be taken as my declaration of citizenship, actual legal residence and domitile in the State of Florida. ! I
(Insert here any pertinent facts, such as sale of property or business, or relinquEshment of employmetti
at former domicile, removal of family to new domicile, purchase of home, etcJ '"~ti ~
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Lntering daughter in 5th Grade `•.-x
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: ? ~.Y ;ti;e. -t~ 3 • .
aan in 8tb Grade - ~
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i FURTHER CERTIFY that I will comply with all other requirements af a legal resident of this State. ~
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f FURTHER CERTIFY that I have no intention to return to my former rlomicile, and I intend to remain in FOR7 ~
PiERCE, SAINT IUGE COUNTY, FLC~RIDA, permanently. ~
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~ c~ (Name)
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' ~ Joe Ceci1 Bissette
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. . (Address)
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~ . , t`' 7 Oic tober 65 ~
~~t.+ti~'to`8nd subscribed before me this _ day of - , 29 . +
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ROGER POITRAS -
CLERK CIR T COURI' Notary Public
BY D.C. My Cammission expires i
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(To br ~xec~»d ih du~licate snd oripinal ~i{ed with Ci~rr~c Circuit Court, and dup+icah witlt Tax Atttswr,)
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