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Declaration of Domicile and C:tizenship
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TO THE ~TATE A~ln COUNTY TAX ASSE~OR,
Si . LUCIE COUNTY, FLORIpA
This ~s my declaration of Dom~cile and Citrzenship in the State of Florida that I am fili~g this day in accordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
i was formerly a lega! resident ot ~a''cnn _ _~~~~~rt.'?a
(City) (State)
9~t'r. ~ivenue
and I resided at _ _ However i have changed my domi~ile
(Street and Number)
to and am and have been a bona fide resicfent of the State of Florida since 3~ _ day of
_ GCtober . 19_ 6~ , and I reside at I~4~ Suttl].s~-,~?v~
- ~ (Street and Number)
FORT ~IERCE, 5AIN? LUCIE COUNXY, FLORIDA
and this statement is to be taken as my declaratiori af citizenship, actual legal residence and domicile in the SfaTe af Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinguishment of empioyment
at former domicile, remova! o{ family to new dnm;cile, purchase of home, etcJ
~~i~ `~1d~~EG4RDED
~s~a~~ i~hi:~' res~ dence K
.
65 t~~V I A,if ~;1 ~.ti
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I FURTHER CERTlFY that I wi!I comply with all other requirements of a legal resident of this State.
I FURTHER C~RiIFY that I have no intention to return ~o my former domi~ile, and I intend to remain in FURT
PIERCE, SA~NY Ll1Ct~ COUNTY, FLORIDA, permanently_
. : - ~ _ _c
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(Name)
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~ , Jep R. uoberts
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Sworn to and subscribed before rre ihis day of , 19 ~K
ROGER POITitAS ~
CLERK RCUIT URT Notary Fublic
gY - D.C. My Commission expires
(Ta be executed in dupl+cate and ariginal filed with Clerk Circuit Court, and dupticate with Tax Assessor.)
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