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~eclaratio~ ot Domicile nnd Citiz~~nship
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TO THE STAiE AND COUNTY TAX AS5ESSOR,
Sl. LUCIE COUNTY, FLORIDA:
This is my deciaration of Domicile and Citizenship in the Stare of Florida tha! I am filing this day in accordance and
in conformity with Chapter 222, Section 222.17, Flarida Statutes.
I was formerly a legal resident ~Plo ~k?at V~~--_-___ _
(~~ty) (State)
and I resided at ~o6iLe ~$0 _ . However I have changed my dom'sc.lle
(5treet and Number)
to and am and have been a bona fide resident of the State of Florida since _ day of
K~~ , 196~ , and I reside at BOOC ~~~l3
- _ . - _ _ _
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTIf, FLORIDA
and this statement is to be taken as my declaration nf citizenship, actual legal residence and domicile in the State of Floride.
(Insert here any Fertinent facts, such as sale of praperty or business, or relinquishmenT af employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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ffi~tering Child in School F~ ~~1 R E C 0 R D E p
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RooK
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~ss r~o~ i 5 aM ~o : 58
ROGi~~-, t°... : uL~RK
.:T. LUCi~ C~UN7Y, .
FLORIG~,
I FURTHER CERTIFY that I will comply with all other requiremenis of a legal resident of this State.
I FURTHE~C CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
PiERCE, SAINI' lUCIE ~OUNTY, FLOR{DA, permanently.
, - , A Mrs. xauc~is (3ibs~ a---
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Swam to and s~bscribed before me this day of ~'!~ber - ,~9 b5 .
RtJGER POITftAS -
CLERK CiRCUIT COU(tT Notary Public
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gy b~ D.C. My Commission expires .
BaQ~ ~3O 55~
tTo 1» ~xecuhd in duplicate snd origir~sl file~d +aith Clerk Circuif Court, and dupliut~ with Tax Ass~stor.) ~