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O~cla~atioti ot Domicll~ and Citls~nship
~ 4 .
TO THE STATE AND COUNfI/ TAX A~;iSESSOR. 152~Q4
ST. LUCIE ~OUNTY, FIORIDA:
This i: my decla~atio~ of Oomidle and Citizer?ship i~ the St~ro of Florida that 1 ~m filln~ this day in aooordano~ and
in oonformi~y with Chapter 2?2. Settbn ?22.17, flo?ida St~tul~s.
I wss formerly a Isqal rosid~nt of Q~p '
Kty) (Stat~)
and I msided et 301 E. (irss~citrood tve. - . HowevK 1 hev~ chup~d my domWle
(Stnst and~ Number)
ro and am and hsve been a bona fide retident of tl» Ststs of Florida sinoe Ut day of
. 19~ , and 1 raide at 181 Iiaran~a ~~ns.
(Street and Numbsr)
FORT r1~CP~, SAINT tijCiE COUNTY, RORIDA ~
and this statement is ro be taken as ~my decla~'ation of citiunship, actual Ipal nsidenos and domidl~ in the Sta» of Horida.
(Insert here any pertinent fsct:, :uch a: sale of property or bu:iness, or rolinqulshr~t of employmsnt
at former domicils, removal of family to nsw domicile, purcha=e of home, etc.)
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FILTNt3 FQR ~F,~D PU~~O?S~S ~
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'61 JAI1 19 PM i: 46
. 152~4
ROGER P017RA~
GLERK C1RCUIY C01~'
1 RIRTHER CfRTifY tfiat i wil{ aomply with slt otF~ requtr~,m~nri of a Ipai ~iderrt of this Stete.
1 FURTHER CERTIFY that 1 have no intention to retum to my former domic,ile, and 1 tnte~d to remsin in FORT
PIERCE, SAINT lUCIE COUNTY, FLORIDA, permanently. 4
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S,~J~~y~; ~C~G'~,r.~'j's-:. (Address)
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_ • . ~ : p, - yth Janau'!r 6
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;;A' '~a•~~s~bsuibed before me ihis 1 da of
~ : ""~`~.l' S Y . 19
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- Notary Publk
BY D.C. My Commiuion expires
(Te b~ ~csarhd M drplicM~ anii ai~inal fN~d w1i1~ Ci~lc Cinrif Co~irf, and dupNcal~ wilb Tax A~ora
n~164 ~ ,747.
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