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Declaration ot Domicile and Citizenship ~ .
TO THE STATE AND COUNTY TAX ASSESSOR. ~ .~~~.541
Si. U1CIE COUNTY, FIORIDA: ~
This is my declarotion of Domicile and Citi=enship in the State of Florida that 1 am filing this day in aooo~danos and
~n confo~miy -wif~i Chapte~ 222, Section 222.17, Flo~ids Statutes.. ' .
I was formerly a legal resident of • Brookf ield I>
tGity) (State)
and I resided at _ 3741 M8diS0~ ABe. s . However I hsve changed my domitile
(SNeet and Number)
b and am and have been a bona fide resident of the State of Florida since 4th day of
MAq ~ 19 66 ~ a~ ~ reside at 2233 North 47th street
(Street and Number)
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FORT PIHtCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Horida.
(Insert here any pertinent facts, such as sale of property or business, or retinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
Bstabiishi
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' 1 FURTHER CERTIFY that 1 will oomply with all other requirements of a lepal resident of this State.
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1 FURTHER CERTIFY that I have no intention to retum to my former domicjle, and 1 intend to remain in FORT ~
PIERCE, SAINT IUCIE COUNTY, FLORIDA, permanently.
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~~~5wom to and subscribed before me this ~ 4th day of _Tanuary , ~q 67,
ROGER rORRAS
CfRtUIT Notary Public ~
g ~ D.C. ~ My Commiu'ron expi~es -
~
- Re b~ ~x~aM~d in duplicat~ and ori~n~l fil~d wilb Cl~ek Cie~arit Couet, and duplk~ wHh Tax Ass~s~or.)
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