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~ Deciaratlon ot Demicife an iti
, d C zenship
I
TO THE STAIE AND COU~JTY TAX ASSESSOR,
51. LUCIE COUNTY, FLO!2iDA:
~ This is my declaratiun of Dom~cile and Citizenship in the State of Fbrida that ! am filing this day in accordante and
~n confarmity with Chapter 222, Section 222.17, Florida 5ta~utes
! was f~rmerly a legal resident of (1 ~ S~ N.
' (City) (State)
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and I resided at ~f _ _ However I have changed my domi~ile
+ (Street anc9 Number)
~ to and am and have been a bona fide resident of the State of Florida since
, - - - - - day of
t ~/f
- _ C~ , 19__~~J, and 1 reside at _ ~ ` ! _ S ~Q u R-~-- -
(Street and Number) `
I FORT PlERCE, SAIN7 LUCIE COUNTY, FIORIDA
f and this statement is to be taken as my declaration of cit~zenship, actual legal residence and domicile in the State of Florida.
i (Insert here any pertinent facts, such as sale of properiy or bus;ness, or relinquishment of ernployment
at fc,rmer domicile, removal of famiiy to new• domicii~, purchase of home, ett.)
` ~terino children in schoo2 F1L ,
. s, .~r.p
; _ ir~al ~
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_ ~ 0 0 K
Establis~ing residence
9 ~ ~ .
. ~~t )U~(~ ~ 22
. , RO~~ }L;-:),;;~'.,c R
, . fiLO ~~UNrr K
~ . R1DA
I FURTHER CERT'iFY ihat ( wii( compfy with ail ofiner requirements of a legal res~dent of this State.
I FURTHER CER7IFY that I have no ir.iention to return to rny former domi~ile, and I intend to ~emain in FOi27
PIERCF, SA.IN7 LUCIE COUNTY, F~ORIDA, permanenily.
l
' Gerald G.(Name) imCOO[
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(A ress)
Swom so anc! subscribed before me this day of ~ 1.9 .
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aoGEa Po~r~.as . • ~
CLERK ClRCUIT C~UR7 ` Notary Pubiic ' ~~s
pOTAR'+f PUBIiC, S1ATE oi : ~,:R;.;:, a,
MV COM41~i15SI0N EXPIRES MAR. S, 19Eib
BY D.C. My Commission expires `_~dM f~ W. Dilsteihont
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I ~ (To be pX@CtitQd Ifl CIYPIt6it@ and original filed witl~ Clerk Circuit Co~~t, snd duplicate with Tax ll~assor.)
' ~~~K 130 3~~
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