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Oeclaration ot Domicile and Citizenship j
- j~3i98 ;
TO THE STATE AND COUNTY TAX ASSESSOR,
S1. LUCIE COUNTY, FIORI~A: i
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This is my declaratio~ of Domicile and Citizenship in the State of Florida that I am filing this day in aocordancs a~?d
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a legal resident of -~~~~2LC4llA~F V~ rg~ n i a
(City) (Stsro)
o~d i~es~ded ar ` 9A20 _Southwick Street , Faitf ax ~,,,reV~ ~ hava chan9ed my domic~le
(St~eet arx! Number)
ro and am and have been a bona fide ~esident of the State of Florida since 1St day of
_ April , ~q 6~, a~ ~ reside at 430 h~'rima Vista Bivd ~
(Street and Number) ,
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of cit'zenship, actuai legal residence a~d domicile in the State of Horida.
(I~sert here any pe~tinent facts, such as sale of property or business, or relinqui:hment of emptoyment
at former domicile, removal of family to new domicile, purchase of home, ett.)
Establishing residence
ST,~ ~UCI ~`JQ R~~o
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1 RIRTHER CERTIFY that I will oomply with all other requiremenri of a leyal resident of this Stste.
~ 1 FURTHER CERTIFY that I have no intention to retum tn my former domitile, rnd 1 intend to ~emain in FORT '
PIER~`E, SAINT LUCIE COUNTY, FLORIDA, permanently.
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Sworn to and subsc~ibed before me this day of . 1
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ROGER PORRAS ~
CIRCUR COURT Notary Public
gy ~'L D.C. My Commiss'wn expires ~
(To b~ ~x~cuhd in ~plicat~ and ori~inal Al~d wilb CIKIc Cinuif Carr~, and duplicafa wi* Tax Assa~or.)
BOOK169 PACE2619