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Dealuatlo~ ot Oomicil• and Citl:~nship
~ ~ 14'749~
TO THE STATE ANO COUNTY. TAX ASSESSOR, •
Si. U1CIE COUNTY, FIORIDA:
This is my cleclsration of Domicile and Citiz~ship in the Stats of Florida that 1 am filinq this day in ac~oordana and
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in Qonformity with Chapter 222. Sxlion 222.17, Florida Statutes. •
1 was formerly a legal ~esident of Ts~s~• _
~C;ty~ (Stah)
and 1 ~asided at ~n~ 6 . Howevsr 1 have chan~ed my domk3le
(Street and Numbe~) -
ro and am and have been a bona fide resident of the Stsie of Florida sinoe ~ ~ ~Y ~
~ , 19~ . and 1 roside at ~.~10 S• 48th ~'e~fi. _
- . • . (Street and Number)
I~ORT SAWT LUCiE COUNTY, RORlDA
and this statement is to be taken as my declaration of citizenship, actual le~al ~as'~denoe and domidle in ths Stats of Horida.
qnsart he~e any pertinent facts, such as ssle of property or business, or relinquishment of employment
et fo~me~ domicile, ~ernoval of family fo new domiale, purchase of home, etc.)
Zntering ]cat,h~ Jw in 7th t}rad~ '
~ JsrYy Katt~hs~r in 4th t~ra?ds
! Ja~es4lean in ].st (irad~ <
PIL.ED I?ND R_Fi~l~ll.~' .
~~RECORD VER~~~ '
i _.~~a~
~ '66 AUG 6 PM ~ : 23
147'492
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I ROG~R POtTRAS -
CLERK CIRCUIT C~URT
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1 FURTHER C'ERTIFY that I will oomply with all other requirements of a la~al ~esident of this State.
1 FURTHER CERTIFY that I have rw intention to return to my former domidle, and I intend to remain in FORT
PI~, SAINT .L~~~QUNTY, FIORIDA, permanently.
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~ } _ ~ ~ r ' Jirass ~Iitthsx Bea:'d
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"..'.;:~rr.,: 8 ~t~gt~st , 19~_.
Sv~rom ~o'snd subsaibed before me this day of g •
ROGER
w~ Cp~ Notary Public
gy D.C. My Commission expires _
(To b~ ~artad ie dupiicat~ and oei~inal AI«! with CNrk Cira~lt Court, aad duplieah whh Tax As~or.~
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