HomeMy WebLinkAbout0011 oecfera~~Qn of Domicile ahd Citisenship .~4y~f3 ;
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TO THE STATE ANO COUNTY TAX ASSESSOR, I
51. LUCIE COUNTY, F~ORIDA:
This is my declaration of Domicile and Citiz3nship in the State of Florida that I am filing this day in accorda~~a and
~n conforn~ity with Chapter 222, ;ection 222.17, Florida Statutes.
Lolumbus ~ Mississippi
1 was formerly a legal resident of _ _ _ _ _ _ _ _ _ _ - - ~
(City) (State)
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a~d ~ ~es~ded at ._.___1415 ___Garden Rg~d__ . However l have changed my domitile i
(Street and Number) ;
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to and am and have been a bona fide resident of the State of Ftorida since _ 3 Ot Ii day of ~
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OCtObel 19 and I reside at _~Q~ Q11e
p~it.f'e-- -
_ (Street and Number)
FOitT PIERCE, SAINT LUCIE C9UNTY. FLORIDA
and ti~is statement is to be taken as ~ny declaration of citizenship, actual legal residence arxl domicile in the State of Horida.
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(tnsert here any pertinent facts, such as sale.~f prope~ty or business, or relinquishment ot employment ~
at fat.^.~er domicile, removal of family to new ~amiciie, purchase of home, etc.) ' :
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~ntering children in schos~l - -
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~ FIlEO ANO RECORQED
ST. LUCIE COUNTY. F~p,
R£CORD VERIFIED
- '~S OCT 3 I A~I 10 : I 2~ a
' 149563 ,
~ nOvErZ AOlTR~S ~
I GLERK CIRCUIT COURT ~
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I FURTHER CERTIEY that I wil) comply with all other requirements of a lega) resident of tfiis State.
i r turn to m former domicjle and I intend to remain in FORT ~
1 FURTHfR CERTIFY that I have no intent on to e y .
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PIERCE, SAINT„~UC~E COUNTY, FLORIUA, permanently.
_ .~i ,~C~~~ k
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; (Name) ;
. • . _ ' " me s Ad ams `
~ . . ` ~
~ (Address) ~
ra _i - _
~ 3~ October 66 ~
Sworn to and subicribed before me this day of . 19
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~ ROGER POITRAS ~
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~ C K CIRCUIT CO RT Notary Public ~
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~ gy D.C. My Commission expires ~
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~ (.T:~ be sxsa~4ed in dupliuh snd ori~insl filed with Cltrk Grcuit Court, ar~d duplicsM wifh Tax Ass~ssor.)
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