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Declaratio~ ot Dom~~ile and Citizenship
70 THE STATE AND CGUNTY TAX ASSFS~OR,
51. lUCit COUN7Y, FLORIDA
Tnis is my deciaration of Dom;u~e and Cit~zensh~p in the State of Florida that I a~7i fil~ng this day in accordance and
in conformity w~th Chapte~ ?.22, Se:tion 2?2.17, Florida Statutes
I was formeriy a le~ai ;esident of B~l~p ~~~i~
(Cityl (State)
and ! resided ar ~~r~ ~1e1'ive2g However I have changed my domiCiie
(Street and Numberl
to and am and have been a bona f~de resident of the Stale of Flo-ida s~nce 3 _ day ot
November 65 Sailf`.Lsh Trai]e r Courty S 25th S`t.
, 19 and ! reside at -
~ ~X (Street and Number)
PORY PIERCE, SAINT IUC~E GOUNTY, FLOaIDA ~1~'~~ ~u2'~
and this statement is to be taken as my declaration of citizenship, actual legal residPnce and domicile in the 5tate of Florida.
(Insert here any pert~nent facts, such as saie of oroperty or busir.ess, or reiinquishment of employm.~n?,~ -
at former domicile, remcval of family to new domicile, purchase of home, etc.)
Entering Jayce Anu in ?th Grade ~
^ Ja4na~sCecil in l~th ('rt~ade
„ Barbara Louise " F'!
~ Carol Jeaz in 3r+d C~rade ~~~r~.~~ DED
Donna Marie in 2nd Grade _
_ __ap~
1 ~
a~ f r 1~~ s ~f' ~t •
Z . 21
rro:- - '
y" :
~."^t` CO'' `"`~R
Fi pqU,'~~.ry K
I FURTHER CERTIFY that I will comp~y with all other requirements of a legal resident of this State.
i FURTHER CERTIFY that I have no intention ro r~turn to my forrn~r c!omi~ile, and I intenc! to remain in FORT
PIERCE, SAINT LUCIE CUUNTY, FLC~RiDA, permanentiy.
1~• ~ r
_ ~.~sr~/4 . -~L..~~3.~` ~^~'~1Y`'-
(Name)
. , . s; .
~ Helen Blaakbr~z~
~ • (Address)
. ' ~
. Sworr, ta and subscribed before me this 5_____ _ day of _ NOV~x!'tboi' _ ~g
ROGER POITRAS - - _ - _ .
CLERK CUt7 COURT Notary Public
g D.C. thy Commission expires
Y - - 4 - - -
(To be executed in duplicate and original file~l wi4h ~lerk Circuit Court, and duplicate with Tax AssessorJ
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