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Deciaratlon ot Domicila and Cittzenship 15238i
TO THE STATE AND GOUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, FLORIDA:
This is my declarotion of ~omicile and Citizenship in ths State of Fiorida thst I am filin~ this dsy in sooordanoe and
~n oonfo~mity with Chapte~ 222. Section 222.17. Florida Statutes. ~
1 was formerly a legal ~esident of Louisvills RentuCl~
(~ity) (Stah)
and I resided at 690~ Bedt~'d I,at'~s . However 1 have chanqad my domidle
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ~2~ dsy of
November ~ ~ g~ar Roube, Jensen Beach, Florida
_ , 19 , and 1 reside at
(Street and Number)
FORT PIERCE, SAINt LUCIE COUNTY, FLORIDA " f
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Horids. :
(Insert here any peninent facts, such as sale of property or business, or relinquiahment of employment
at forme~ domicile, removal of family to new domicile, purchass of home, etc.)
Homeatead.Purposea
RECORO~;~-, ~
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3T~RE ~R~ VsZ3a~-
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I RIRTHER CERTIFY that I will oomply with al) other requirements of a lesal resident of this State.
I FURTHER CERTIFY ihat I have no intention to retum to my former domiti~e, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
~ ~ ~
(Name) Jack B. Moore ~
:,:t:::r;;;r,
~ .•:.ii~,~ic~~?~;';;~ Star Route, Jensen Beach, Fla.
. , . ~
= ' . ~ Q ; (Address)
„ :
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`j'.~"•~w,o,rp~o and;~s~ribed before me this 3~t day of J~~~ . 19~.
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'ICdGER • ~OITRAS
CIERK CIRCU tOU Notary Public
~
gy D.C. My Commiuion expires
(To b~ ~x~cur~d in dupliut~ and ori~insl fibd wilh Cl~rlc CirarN Cou~f, aeK1 duplica» with Tax A~shsor.~
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