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Declaration ot Dorr~icile and Citisenship 144252 ~
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TO 7NE STATE AND COUNTY TAX ASSESSOR,
51. IUCIE COUNTY, FIORIDA:
This is my declara~ion of Uomicite and Citizenship in the State of Florida that I am filing ihis day in accordance and
,r, confo?mity with Chapter 222, Section 222.17, Flo~ida Statutes.
1 was formerly a legal resident of ^ ~ ~
~ _ ~ I -r-Y- _ _
(C;ty) (State)
and 1 resided at _ l7 _~u T G' E~S___._ /T_v~__ . However 1 have cha~ged my domiGile
(Street and Number)
~o and am and have been a bona fide resident of the State of ftorida since __~~~'r. _`'s ~ day of
. 19~ and I reside at _ I
~l~ C /
(Street and Number) t
FORT PIERCE. SAINT tUClE COUNTY, FIORIDA
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and this statem~e~t is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Horida. _
(Inse~t hcre any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of horne, etc.)
FI ~~A~0 REC RDED :
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~.44252
ROGEr~ ~'~;i'~°;:~S. ~LERK~
ST. LUCIE COUN i Y.
F~ORiDA
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I RJRTHER CERTIFY that 1 wil) comply with all other requirements of a legal resident ot this State.
; 1 FURTHER CERTIFY that I have no intention to return to my former domiCile, and 1 intend to remain in fORT
PIERCE, SAtNT LUCIE COUNTY, FlORIDA, permanently. ,
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(Name)
' ~N::: ~ t u il7~r
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~ ,L~ifs Tk' ~,E ~ er.' .~'o,~
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- (Address) ~ 1 ~ ' ~n ~ i
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Swom to and suburibed before me this day of
_ ~`~?l:, ~'`,y:
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- ROGER PO{TRAS
GtEitK CtRCNIT COURT Notary ublic
~ By O.C. My Commission expires
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" (To bs ~xecuted in dupliuM and original ~iled with Clerlc Circuif Court, snd dupliuh wilh Tax A~ssor.)
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