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Declaration of Domicile and Citizenship ~
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TO THE Sl'ATE AND COUPJTY TAX ASSESSOR, ~
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51. IUCIE COUNIY, FLORIDA: ~
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This is m deciaration of Domitile and Citizensh;p in the State of Florida that I am filing ihis day in accordance and ~
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in conformity with Chapter 222, Section 22?..17, F!orida Siatutes.
! was formeriy a lega! resident of LOpB ~"~~31?~ _`l,'~ _ _ ~it_Y~'k- _
(C;ty) iState) 3
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and I resided at l~536- ~~t21 F18C6 Long T~16~nd_ G1ty However 1 have changed my domi~ile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since Zbt~ _ day of
I~~~ , t96~ , and I res~de ar ~?~5 w9e. J S~land Gardens
(Street and Number) ;
FORT FIERC~, SAINT LUClE COUNTY, FLORIDA
and ihis statement is to be taken as my declaraiion of citizenship, actual legal residence anc~ domicile in the Stete af Florida.
(lnsert here any pertinent facts, s~ch as sale of property or business, or relinquishment of employment ;
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at former domicile, removal of family to new domicile, purchase of home, etc.)
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Establ~shing residency ;f~~~~ . . :
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I FURTHER CERTIFY that ! wil! comply with all other requirements of a legal resident of this 5tate.
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I FURTHER CERTIFY that I have no intention to return to my forrner domicil.e, and I intend to remain in FOR7
PIERCE, SAllv7 LUCIE CGUNTY, FLORIDA, permanently. '
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Name} ;
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C. Regina DnFresna
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.:,,,$w~r?+tt~`and su~scribed bPfore me this _ _27~1_f___ _ day of _ _~~~~Qx - , 14~~s
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ROGER POITRA5 - - ;
RK CIRCUIt COURT Notary Public ~
~ ~~~L~~ _ D.C. My Commission expires ~
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; (fo be exscuted in duplicate and original filed with Cierk Circuit Court, and duplicite with Tax Assessor.)
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