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Declaratlo~ of Don~icile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, ~~;~yyy~•y ~
~V r ~
Si . lUC1E COUNTY, F~ORIDA:
This is my declaration of Damicile and Giti:enship in the Stats of Florids that I am filinp thit day in acoordanoe a~d
~n oo~formity with~ Chapter 222, Section 222.17, Florids Statute~.
Coluvnbiis Miaaisaipp!
1 was forme~ly a legal resident of
fCiy) (Stah)
and 1 reaided at 5 Bcoc 638 . However 1 hsve charpe~l mydomidle
(Straet and Numbe~)
to and sm a~d have been a bona fide resident of the State of Florida since day of
_ '~~a~ . 19~, snd 1 reside at _ 3~0 Dicksen Dri va_ Wl.i+,g C1 tv
(Street snd Numbe?)
FORT PIERGE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be tsken as my declaration of citizenship, actusl teqdl residenoe and domicile in the Stste of Florida.
(fnsert hera any pertinent fads, such as sale of propery or butiness, or rolinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
EnteMng ~nis Adams in Jr. high _~scbool RILEp aND RECORpgp
ST. LUCIE COUNT1r. ~u. `
" Brenda and Glenda Adams in SLement,siy ~ RECORD VER~F~ED '
~ -.~~-''c~' ~
~T JAN .~3 AN ~p ; 36 '
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koc~R ~o~rAas ~
~~RK CIRCUIT COURT ~
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I FURTHER CfRTIFY that i will oomply with aN other raquirert~enb of a IeQal rssldent of thls State.
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1 FURTHER CERTIFY that 1 have no intention to retum to my former domi4le, and I intend to remain i~ FORT ~
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. . _
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J, .c`,-'~'~',,, - (Name) N`~
`y ' ; v~ ~L . - Mrs ~nest Adaaa
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•~..^:~•'CC ;
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Sworn ro and subscribed before me this ~3~ day af - January ~ 19_~
ROGER POITRAS
CIRCUR Cqy1RT Notary Public
~.,.f/
s ~''E'~'' D.C. My ~ommiuion expires
Ro b~ ~x~cut~d i~ duplical~ an~ orioind fil~d whh Ciwk Cira~it Coue~, and duplicat~ w~ Tax A~sor.)
g~164 ~ 858
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