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Declaration ot Domicile anct Citizenship ~~l f}f~(
TO THE S1ATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, FLORIDA:
ihis ~s ~~y declaration of Domicile and Citizensh~p ir, the State ot Floric'.a that I am filing ihis day in accordance and
in conformity with Chapter 222, Section 222.11, Fiorida Statutes.
I was formerly a legal resident of ~Y~dF.ZlCrl~ Long Island ~eil Yp!'I[
(City) (State)
lsth
!al.t N ~.th ~treet
and I resided at However I have changed my domi~ile
(Street and Number)
to and am and have been a bona fde reside~t of the State of Florida since ~8 _ _ day of
- 2021 Hi11ss Conrt I~d
NOV81~b~Y' , 19.6~ , and I reside at
- - - - _ -
(5treet and Number)
PORT PI~RCE, SAINT WCiE COUNTY, FtORIDA
and this statement is to be taken as my declaration of citizenship, actua~ legal residence and domicile in the State of Flarida.
(Insert here any pertinent facts, such as sale of Froperty or business, or relinquishment of employment
at farmer domiciie, removal of family to new domicile, purchase af hnme, etc.}
FI ANO t4EC~RDE~
~~a ~ • • ~ ' ~OflK
Entering Danr~y A. jriolf ia 7th Grade
" Katraleen ~th Wolf in 2nd Gaade L~
'65 N011 3 0 AM i I: 2 3
l~:~i~f3i~ ~
RQG~R + ftH~, CLERK ~
ST. LUCIE COtJNTY,
. FLORIBA
.
• ,
I FURTHER CER'iiFY that I v~ill comp!y with all other requirements of a legal resident of this State.
I FJRTHEf: CERTIFY that I have no intenticn t~ return to my former domi~iie, and I int2nd ta remain in FORT
PIERCE, SAINT LI;CIE COUNTY, FLORIDA, permanently.
. . . ' _ ~ -
, • (Nam
~ - • ~.l?3ert Wo
. . (Address)
' ~ ,
Sworn to and subscribed before me this _._._________.~0 day of ~~~~~?r_.___.__- , 19 b~.
ROGER POlTRAS
CL~RK CiR T COURT Notary Public
gy _~_____r~_ -C~___.___-____ U.C. My Commission expires
~ (To be executed in dupticate and ariginal filed with Clerk Circ~it Gourt, anci dup{icste with Tax Assessar.)
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