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Deci~ration of Do~ni~ife and Citisenship
13~S~j'~
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, FIORIDA:
This is my declaration of Dnmicile and Citizenship in 4he State of Florida that I am filing this day in actordance and
in conformity with Chapter 222, 5ettion 222.17, florida Statutes.
I was formerly a?egal resident of ChiC8~0 T11irio~,3
(City) (Steta)
Lt~tlt N. pu~tin Blvd
and 1 resided at - - - _ - - - However I have chanyed my domiGle
(Street and Number)
to and am and have been a bona fide resident of the S4ate of Florida sinte _l~ day of
-----Ja~~'_ 19__b~, and I reside at __~~_.~~?~`_Dz'].V~ P02`t St. ~t;ie
(5treet and Number) -
FCfRT PIERCE, SAtNt LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Flor9da.
(Insert here any pertinent tacts, such as sale of property or business, or r~linquishment of emplayment
at former domicile, removal of family to new domicile, purchase of home, etc.)
F?L
Es~k.abl~.shing residenee "i REC Rp~p
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l,,t;,;~„~•;. 40K
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Y~: - . ~ 28 P;4 I , ~
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( FURTHER CERTIFY that I will c~mply with all other requircments of a(sgal resident of this State.
-1"~URTHER CERTI~Y that 1 have no intention to return to my former domi~ile, and I intend to remain in FORi'
Pi~RC~E,~$A'1MT LUCiE CC3UNTY, FLORfDA, permanently. ~
w~:~~Y _ ~
~.~S•~t'" _ • s~ ' ' ` / f , .
j~` . . s~ / ~F
~ - _ . . ~ " (Name) .
~
~ ~ Ed~,nn E. Fr~iec~nan ~
~ . .?y 7 ~ y J
~ ~ r'~ (Address)
Swom to and subscribed before me this _~8 day of ~ aCtObe2^ ~ iq ,b5
ROGER POITRAS
CLERK tt tJt~ CdURt Notary Public
gY - D.C. My Commission expires
(To b~ ~xstufa~d in dupliut~ arid original ~itsd with Ci~rk Cirtuit Court, and duplica» with Tax Ass~.)
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