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Declaration of Domicile and Citize~ship
TO THE STATE AND COUNTY TAX AS5E550R,
S~ . LUCIE COUNTY, FLORIDA:
lhis is rny decla~ation of Domicile and Citizensh~p in the State of Florida that I am tiling this day in accordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was former~~ a legal resident of Nort?1 riadison Ohio
- - - -(City) _ . (5tata)
and 1 resided at _ 255 ~ed i~ird Road _ . Nowever I have changed my domic,ila
(Street and Number)
to and am and have been a bona fide resident of the State of F!orida since day of
Octaber 65 1301. Valencia '~t~enue~ Paradise Park
- , 19___ , and I reside at -
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORlDA
and this stetement is to be taken as my declaration of citizenship, actual legal residence 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, remaval of family to new dom~icile, purchase of harne, etc.)
~ILED AND RECORDEO
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EstabliUhin residence '6~ Z~ i I. 2
~'n~er.~r.g John in 7tn Grade ~i3;~~ ~
D~.ane in l;th ~rade ROGEE? PJ~ i f~.;~, ~~ERK
ST. LUCIE CO,t~NTY.
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I FURTHER CERTIFY that I wil! comply writh al) other requirements of a legal resident of this State.
I FURTHER CER7IFY that ! have no intention to return to my farmer domic,ile, and I intend to remain in FORT
PIERCE, SAINI' ~UGE COUNTY, FLORIDA, per~rianently.
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~ . . . ~ (Name)
• Carol Bliss
~ " ~ (Adciress)
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Swom to and subscribed befare me fhis ._____2 day of -___»`ovem~er ~ 19 6
ROGER POfTRAS - -
RK CIRCU COURT Notary Public
gy _ D.C. PV1y Commission expires .J..~
(To be ~xecutod in duplicate and orig~na) filed with Cle?k Circuit Courf, and duplicats with Tax Ass~sso~.)
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