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Declaratlon ot Domicile and C tt sh p
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TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, FLORIDA:
This is my decla~ation of Domicile and Citi=enship in the State of Florida that I am filiny thi: day in aooordenoe and
~n conformity with Chapte~ 22Z, Section 222.17, Florida Statutes. ,
I was formerly a legal resident of S~'BY ~0 _
(~ity) (State)
1!~ S'he~Cidat~ ~v~9. .~„Vev~r 1 have chanqed my domicile
a nd 1 resided at
(Street and Number) •
ro and am and have been a bona fide resident of the Stste of Florida sinte 2~~ dsy of
January 6~ 2309 01¢eechobee Rd.
, 19 , and 1 reside at -
- (Street and Number) ~ f
~
FORT PIERCE, SAtNT LUCIE COUNTY, RORIOA ~
and this statement is to be taken as my declaration of citi:enship, actual legal residenos and domitile in fhe Stata of Horida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchass of home, etc.)
ENTERIN(i QEIILD IN P'tTPLIC St~i00L
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sT, wc~E cv~'~
RECORD VERIF#~0
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I FURTHER GERTIFY that i will aomply with all othsr rsqui~ements of a(e~al resident of this State.
I FURTHER CERTIf.Y that I have no intention to retum to my former domicjle, and I intend to remain in FORT
PfERCE, SAINT LUCIE COUNTY, FIORIDA, permane~tly.
L..
~ ~ (Name)
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• i 7 C - , BAR'SAR? QUE6N
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:,$w~~f~~~z~scribed before me this day of . •
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U11 COU ~ Notary Public
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gy D.C. My ~ommission expires
(To b~ ~oacuhd in duplicab and ori~inal Bf~d with Cl~lt qra~if Court, and dvplkst~ wifb Tax Aswssor.) ~
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