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D~cla~ation ot Domtcil~ and Citis~nship 151~4
TO THE STATE ANO COUNTY TAX ASSESSOR, ~
Sj. LUCIE COUNTY, FLORIOA: ~ •
This is my decla~ation of Oomicile and Citisenship in the Ststs ot Florida that 1 am filin~ this day in sooordanos a~d
in oonformiry with Chapter 222, Ssction 222.17, Florida Statut~s.
_ljcEeespoTt Kasa.
I was forme~ly a le9al ~esident af
KitY) (St~»)
end I ~esided at ~6 ~?ith!'l.led . Hcwevsr I havt chan~cl my domicile
(St~e~t and Number) -
to and am a~d have been a bona fide r~ident of the State of Florida si~oe 2~ ~Y ~
l,te~~,• t9~ , and ~ rostde ar b59 Sandia DriTS Port S~t.Lncis
(Street and Number)
~ORT lHHtCE, SAINT LtKI! COUNTY. RORIDA
and this statement is to be taken as my dedaratwn of citiunship, actual leyai raidenas and domicile in the State of Florida.
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qnsert here any pertinent facts, such as sale of propehy or business, ~ mlinqui~ment of employmsnt ~
at former domicile, ~emoval of family to new domicile, purchass of home, etc.) €
Eatablishing reaidene~: ind ~11 a~pp],7 for ho~aeatsad
pRDE~ ~
FILE~ ANO RE ,
57.1.UCiE COU~1F
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~ ROG~R PQ1~ Cou~
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I RIRTFIER CHtTIFY that I will oomply with all other nquire~r~ents of e lepsl ~ resldent of this State.
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1 FURTHER CERTIFY that 1 have no intention to retum to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently.
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_ •Sworii"to and wbscribed before me tfiis 16th ~y dan~au~T ,~q 67 .
ROGER
~C ~ Notary Public
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gy D.~. My Commisiwn expires
(To b~ in a~ ori~inal A V~t7 ~nd d~ppa~N wilb Tax As~o~a
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