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Declaration ot Domiciie and Citizsnship
TO THE STATE AND COUNTY T1~X ASSESSOR,
1412?'2'?'
Sl. LUCIE COUNTY, FLOkIDA:
This is my declaration of Domi~ile and Citizenship in the State of Florida thal I am filing this day in atcordance and
E in confo?mity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of _ T~Cd x~~ Jereeg
(Ciry) (5tate)
and 1 resided at ____._BO~~_Lane__- _ However I have changed my domiCile
(Street and Number)
i
~ ta and am and have been a bnna fide resident of the State of Florida since .17~_ _ day of
4
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Dece~nber O~srbrook Dr. P+c?rt ~t.Ldde
~ - . - 19_~i~_, and I reside at _~~~L~--. P'
i' ~ ~ (Street and Number)
~
~ORT PIERCE, SAINT LUCiE COUNTY, Fl.ORIDA
and this statement is to be taken as my declaration of citizenship, actual lega! residence and domicile in the State of Flo~ida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of Employment
at former domicile, removal of family ta new domicile, purchase of home, etc.)
~sitablishing rea idency F~ ~ : N[~ }4, E~ ~C 0 R D E D ~
~ ~'COt~-~OOK ~
~ tiT311 appl3r for ha~t~ataa+d 'f3.5 ~ Q~ E~;'~ ~
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. . CI~ COUis i Y,
; ' ' ' _ , _ FLURiDa
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I FURTHER CERTIFY that I will compiy with all other requirements of a legal resident of this 5tate.
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I FURi'HER CER7IFY that I have no intention to return to my former domiCile, and I intend to remein in FORT ~
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
' ~ ~ : ~ `
~ " X-- . .
. : ASshlo]3 (Name) C1.ine
. .
. ~ • ~
' (Address)
t. r`
21at Decr~ber b5
S'yvp.qti~'to and subscribed before me this day of -~..r- ~ 19 .
ROGEIt POITRAS -
C K CIRCUIT t0 RT Notary Public
,
g `x'`'~'~ ~~.r~.. D.C. My Cammiasion expir~s
Y
Ro h~ ~xseu9rd in duplicate and oeiginal Rled with Cark Cirtuit Court, and dupliesN with 7ax Ass~ator.)
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