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Declaratic~h ot Damicile and ~itizen~hip 4~~a
TO Tt~E STATE AND COUN i Y TAX A~.SESSOR,
Sl. IUCIE COUNTY, FLOR~DA
This is my declaration of Dorn~cile and Citizensh~p in the State of Florida that I am filing this day in accardante and
m conformity with Chapter 222, Sect~on 222.1 J, Florida Statutes.
NeX ~ork City ~TesrYo~k
! was Formerly a legal resident of - - - - - -
{City) (State)
220 -n4 103rd Avenue~ Queena V'i~Ll.~ e
and I resided at _ Howeve; I have changed my domi4ile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ~ _ _ day of
October , b~ 3'i0 l~o Msr Drive~River Par3~
_ , i9_ , and I reside at - _ -
(Street and Number;
PORT PIERCE, 5AItv7 LUCIE COt1NTY, FLOI2IDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(insert here any pertinent facts, such as sale of property or business, or relinquishment of emp?oyment
at former dcmicile, removal of fanr.ly to ne~.v domicile, ~urcha~e of home, etc.)
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Establishing reaidene ~s~ P~?Q(~ ~9 ~ 9 ~ - , ~ j .
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F~OR pAU'~`'r~'.
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i FURTHER CERTIFY 4hat ! will comply with all other requir~ments of a legal resident of this StaTe.
I FURTHER CER7IFY that I have no intentio~ to return to my former domi~ile, and I intend to remain in FORT
PIERCE, SAINT Ll1CIE COUNTY, FLORiDA, permar~ntly.
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, , _ .~~~Z ~ _ _ ~i M -Y i - -
• " , (Name)
. . ,
~ • Fietro SinacorE,
- . ~ (Address)
~9 - ~av of - - - _ Nove.riber - ~9 6
Sworn !o and SUbSGibed before me this ~ 5
ROGER P41'fRAS _ _ _ _ -
CIERK C U1T COUi2T Rlotary Public
By ~ -v1-Gt~s~f_-_'-- D-C. My Commission expires _
~(To be executed in duplicate and original filed with Cfe?k Circuit Caurt, and dupliwie with Tax Assessor.)
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