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, Declaration ot Domicile and Cltizenshlp j"` ~
70 TH~ STAl"E APlD COUNTY TAX ASSES50R,
Sl. LUClE COUNTY, FIORIDA:
This is my declaration of Domici{e and Citizenship in the State of Florida that I am filing ihis day in accordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of RiVCT~t3dt _ COI1t~
- - - - - _ _
~~;ty~ (State)
30 Vezo~na Drive
and I resided at _ _ _ , . - . However I have cha~ged my domicile
(Street and Number)
22nd da of
to and am and have been a bona fide resident of the StatG of Florida since y
August 65 P.O.Hox 168, Stu~rt, ~lo* ida
_ - - 19-- and I reside at - - - _ -
(Street and Number)
FORT FIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence ar~d domicile in the State af Florida.
(Insert here any pertinent facts, suth as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.?
Establi.shin residencr
g F?LED
aND RECORD
~f~~ _ ED
R~OK
~ '&S n., ~ 13 P~ ' ~
~ ~ . _ . , • I y
~ .?fy~• ~ , . tTQ~ C~~~ ~ .r,',P''"-~rv ' `
~w` , ~ - _ ~'r~ ~UC~,~-~~~, .:Lc,i?(
- , . ;~t~~ ~ ~ ~ r~GR~GfaurJ ~ Y.
_ .
. , -
, . . :
i•
1 FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
1 FURTNER CERTIFY that I have no intention to return to my former domitile, and I intend to remain in ~ORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. 1
, L_
. ' ~
~ ~ ~ ' ~ • ame
~ ~ 1 , j Mygno~. ~
. Shirley Flood
~ ~ . ~ . ~ . ' . - -
• ~~r~ (Address)
, y~, ~ ~ ' ~ r
f, . _'..r~~y ~
13 aCfi~ber 65.
~~JOdrq i¢ antii subscribed before me this - day of . 19
.,.-f~
RO~ER TRAS -
CLERK C UIT COURT Notary Public
gY D.C. My Commission expires
(To bo fxacuted in ciuplicair~ and original filed with Clerk Ci?cuit Court, and dupliut~ with Tax Ass~s~o~•)
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