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Oeclaration ot Domicil• and Citiz~nship
TO THE STATE AND GOUNTY TAX ASSESSOR.
Sl. LUCIE COUNTY, FIORIDA:
(his is my declara~ion of Domicile and ~tizenship in the State of Horida that 1 am filirp thi: day in aoo~~danos and
in oonformity with Chepter 22Z. Section 222•17. Florida Stetutes.
1 was formerly a legal resident of ~o
(City) (Stst~)
and 1 ~esided at - 2823 No~`toA DMve . Fiowevsr ! hsve char~d my domidk
(Street and Numbsr)
ro and em and have been a bona fida ~esident of the State of Florids sinee day of
_ Jn 3t , 19~_, and 1 roside at 2305 S118abetdi Avenu~e _
~ (Snset and Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA - ~
and this stbtement is to be taken as my dectaration of cititenship, actual le~a! residence and domicile in the State of Horida.
(Insert here any pe~tinent facts, such aa sala of properiy or business, or relinquishment of employment
at forme~ domicile, removal of family ta new domicile, purchass of home, etc.)
Entering Aiildren in School
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1 FURTHER C~RTIFY that ! wii) oomply wlth all other requirements of a Issal resident of fhit Stata. -
t FURTHER CERTIFY that 1 have no intention to retum to my former domiGte, and I intend to remain in FORT
PIERCE, SAIN1 LUCIE COUNTY, FLORIDA, permanently.
?~f-f/'~
Jack X. Barera, Sr•
(Address)
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, ~i+ve#~„~,.fa(p~f~yb~~~ed before me this ~ dey of Au¢nat y 19~Z.
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8y . D.C. My C.ommissicn eXpifes
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' (Te b~ ~oc~cYNd in dvpWcah and oei~inal fil~d wilb Cl~elc Ckarif Cw~f, aed dvpliaN wifb Tax A~e~a
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