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Declaration af Do~nicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl . LUCIE COUNTY, FLORIDA: i L~ ~}(~4 )
I . ti
This is my d~tlaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordante and
in conformity with Chapter 222, Section 227..17, Florida Statutes.
I was formerly a legal resid~nt of ~E_. - _ - - -
(City) (5tate)
~
and I resided at _ ~L_~'~ . However 1 have thanged my domic,ile ~
(Street and Number)
lat. ~
to and am and have beer, a bona fide resident of the State of Florida since day of ~
inguat 58 16oq N. 11~t,~ st.
- - - _ _ , 19- - , and I reside at _ ~ - - _ - -
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNtY, FLORIDA
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 facis, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
FIZII~G FOR FiQ~[ESTE~D PURP0.g8S
~~t, A q~ RECORBE~ . . '
` I N. l~._ti~C~C~---~ 4 0 K ,
r ~ ` i__ ` . .
I ~ . :
'6S DEC I 4 PM I : I 9 - - , - _ : _
i~~~~~~~~~ - .:.i/ • .
~~GL' fS t"v, ( ~:~5 CLE~ r . ` • ' .
5T. LUCfE COWN"fY, .
FLORtdA i
,
!
I FURTHER CERTIFY that I wil! comply with all other requirements of a le~al resident of this State. ~
I FJRTHER CER7IFY that I have no interitiori to return to my former domi4ile, and I intend to remain in FORT
PIERCE, SAI~1T LUCIE COUNTY, FIORIDA, perman?ntly.
' ~~+zr~;,;.. ~ 1 _
, (Name)
Js~eaL, Tat•
~ ' ~ ~
f ` , ' . ~ - - ~
' " ~ (Address)
, y~ -
° ~ ~~a . ~ .
l~',~' ~~'o. nd subscribed before me this day of ~CembeP _ ` ~ ~q~~ .
. ~
~tOGER POITRI~S
CLER C UIT COURt Notary Public
a
gy D.C. My Commission expires _
(Ta ba executed in dvplicate and ariginal kled with Clerk Circuit Co~rt, and dupli~at~ with Tax Assetfor.)
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