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Declaration of Domicile and Citi:enship _1 ~~t)lE~~~
TO THE STAtE AND COUNTY TAX ASSE550R,
Sl. IUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State ofi Florida that I am filing this day in accordante and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
Qial~ebnrg-- Xiasissip~pi
I was formerly a legal resident of
- - - - - -
(City) (Stbte)
and I resided at _]„QpQ_~Qltt.h ~~x'Q4t - However I havC changed my domic.ile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since 1~~ day o~
-
November ~ q 6~ , and I reside at 121~ -1Qt ~*'+~t
_
(Street and Num er
FORT PIERCE~ SAINT LUCiE COUNTY, FI~RIDA
and this statement is to be taken as rr:y declaration of citizenship, actual legal residence and domicilc in the State of Florida.
(Insert here any persinent facts, such as sale of property ar business, or reiinquishment of employment
at former domitile, removal of family to new domicile, purthase of home, ett.)
Entering Karea in achoal
D
. , ~Il.f~~ '~?~g00K
. . : iN___~__ ,G~~-'t'~
: . . ~ : ~ t0 : ? 3
- - ~ ~ ~ ' '~5 NOV t 5
• ~~-"3~~~~;~~`~ LERK '
~ . ROG~? ~ .
. - SY. LUC?E COUNYY.
, ~ FLORIDA
I FURTHER CERl'IFY that ! will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORi
PIERCE,. SAINT LUCIE COUNTY, FLORlDA, permanently.
, , ~ .
~ ~
(Name)
, ,
~ . Mrs.~enald Foater
, . f
~ ' . ' . (Address)
~ , ` 55
' • , ~ove~ber
~''~r;,~,Sworn to and subscribed before me this -~5~ day af ~ , l9 .
ROGER PO{TRAS - -
LERK CIRCUIT C URT Natary Pub!ic
~ ~~~[.C.-~'~-~ mmission ex ires -
~t~. ~-s~[~ M Co
By - D.C. y P
{To bs ~xecuted in duplicate srcd originsl fi~ed witfi Clark Circuit Court, and dupliwts with Tax Ass~stor.)
Boo~ 13U 53~ e