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Declaration of Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, 1 3(~ ~~'J
Sl. LUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in atcordance and
in tonformity with Chapter 222, Section 222.17, Flarida 5tatutes. •
W~ Hollyrnood ~lorida .
I was formerly a legal resident of - - - - - - - - "
~C;ty~ (State)
7131 NW 27th Street,
and I residec! at - . However 1 have changed my domi~ile
(Street and Number)
to and am and have been a bona fide resident ot the State of Florida since _ --1$ day of
August 19_64 and I reside at ____2a~2_So 19th StlCet
- - - - - _
(Street and Number)
FORT PIERCE, SAINT LUGE COUNTY, fLOItIDA
and this statement is to be taken as my declaration of citizenship, actual legal resicience 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.)
Bstablishing residence
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V•_;~ ST. L~~~~,~iq5, ~~ERK
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I FURTHER CERTIFY that I will comply with all ather requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domiG~le, and I intend to remain in FORT
PIEitCE, 5AIM7 LUC{E COUNTY, FLORIDA, permanently.
C~~' _ C'
; ; ;=~t ~ me)
. ~ ,
' ' ~ -~~yt~
~ i , . Wxlliam J. Iyl~cC~rmick
~ r / ~
(Address)
,
Swotn to and subscribed before me this 2? day of _ ~
tobe r + ~ 9 6~
ROGER PQITRAS
CLERK C UIT COURT Notary Public
gy D.C. My ~ommission expires -
(To bs ~xesuted in duplicate and originsl filad with Clerk Circuit Gourt, snd dupl'sut~r with T+~ Ass~rar.)
BODK 1~~ ~~5
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