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De~laratlon ot Don~icile and Citizenship ~635C$
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY, fLORIDA:
This is my declaration of Uomicile and Citizenship in the Stats of Florida that I am filing thi: day in aooo~danoe and
~n conformity with Chapter ?22, Section 222.17, Florida Statutes. -
I was formerly a legal resident of ~1~~ Washington
~City~ (State)
;
and 1 resided at G18d9tOII.~S.treet However 1 have chan~ad my domidle i
(Street and Number)
to and am anc! have been a bona fide resident of the State of Florida since 15'E~L- day of
_ z
•.,,.a~ , 19~Z, and I reside at 1813 South ~TM~ and N mber)
FORT MERCE, SAINT tUC1E COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the Stab of Horida.
(Insert here any pe~tinent fatfs, such as sale of property or busineu, or ~elinquishment of employment
at fonner domicile, removal of family to new domicile, purchase of home, etc.)
Eatabliah 8esidency for Taz ezemption purposee. -
D
REC~~~F
A~~ N~Y' ,
F~`-LU~1E G~v R~F~~~ ~
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I FURTHER CERTIF1~ that 1 will comply with a!I other requiremenri of a le~al resident of this State.
~ ~
~ intention to retum to m former domicjle and I intend to remain in FORT
~ I FURTHER CERTIFY that I have no y .
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ (Name) Vivisn . Yay
~ .
e:
~
~ , . 1A13
gputh 24th Street
~ , . (Address)
T:. _ ,
..~"e ~ . . .
~ _ : Sworn iQ' arid subscribed before me this 1~t~ day of J~uarv , 19~.
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, ROaER ~0~1TRAS
~ CI.ERK~(RCUIT COURT Notary Publ ic
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~ 6y ~ D.C. My Commission expires
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(To b~ ~xaevhd in duplieat~ and orioinal Al~d whh CIKk Urarit Coue~, and duplieah wilh Tax AsNSwr.)
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