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D~claration ot Domicil~ and Citizenship
TO THE STATE ~ND COUNTY TAX ASSESSOR, t~~ f~~,',1,~~ Ej
Sl. LllCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordante and
in conformity with Chapter 222, Section 222.17, ~lorida Statutes.
Cincinnati
I was forrrierly a legal resident of . _ - - - - - ~'4
(City) (State)
and ! resided at ~t25S Duneden AVe;1Q~ _~2~~__ _ Ho~vever i have changed my domi~ile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ~~h day of
Atlgtlst , ~9d5 , and I reside at Y~ P~`~IlCB3D ~ ve Pert_St~ i.u~j,~_..- -
(Street and Number)
FORt PIERCE, SAtidT LUCIE COUNTY, ~IORIDA
and this statement is to be taken as my deciaration of cit~zenship, actua! legal residence and domicile in the State of Fiorida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former do~ricile, removal of far-~ily to new domicile, purchase of home, etc.)
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! FURTHER CER7IFY ihat I wil{ comply with all other requirQments of a legal resideni of this State.
I~URTHER CERTIFY that I have no intention to returr: to my r'ormer derni~iEe, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUIVTY, FLORlDA, permanently. j
r
- ~S • • - - -
-
` (t~lame) Lea A. Weber
~ 160 Princea~ 1~rive,Port St. ~uci~-_-_-
(Address)
Sworn to and subsc!ibed before•mg.t~is`~~:~__f:__-_._-_ - day of , 19-_.
, , .
RAGER POIYRAS . . ; - -
,~cLERK CiRCtiIT Ct~URT _ • • . Notary Public
/ . . .
gY ~_`~,d.C. ~ My Commission expires ~
(To be exesuted in duplicate and original fit~d with Clerk Circuit Cou~t, and dupticate with Tax Assessor.)
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