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Declaration ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSES54R, :
51. IUCIE ~OUNTY, FLORIDA:
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This is my declarotion of Domicile and Citizenship in the State of Florida that I am filing this day in scoo~danoe and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
I
1 was formerly a legal ~esident of ~C-O~HO.~Ol~a 8 ~
(City) (StaM)
and I resided at ~-~15 I+8lirsl Dri~s However I have chanyed my domidle
(Street and Number)
to and am and have been a bona fide resident of the State of florida since 4th dey of
_ __A~ril i9~, and I~e:~de a~ 1101 Yorlc Avenue - ;
~ (Streat and Number) '
fORT PIERCE, SAIN? ?UCIE COUNTY, FLORIDA
and this statement is to be taken es my detlarot~an of citizenship, ectual legal residente and domicile in the State of Horida.
(Insert here any pertinent facts, such as aale of p~operty or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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Satabliah 8asidsncy tor hoaestead ezemption purpoaee
FILEO AND RECOR~ED ~
ST. l.UC1E COUN7Y. ~LA• ` ,
~ kE.COR~ VFRIrIED 1~ ;
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~ '08 ,!l~N I S PM 3: I
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CLr.RK CIRCt1~T COUR7 ~
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I FURTHER CERTIFY that I wil) aomply with al) other requirements of a leyal resident of this State.
t FURTHER CERTIFY that I have no intention to return to my former domicjle, and 1 intend to remain in FORT
PIERCE, SAINTtU~I~'CQ,UNTY, FLORIDA,_ permanently. . ?
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. , _ _ (Name) ~11~1th Yorris
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`z ~ . . . . ~ . - (Address)
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Swom to and subscribed before me this 15th _ day of .
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~ ROGER POITRAS
~ CLERK CIRCUR CO T . Notary Public .
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~ gy D.C. My Commission expires
~ (To b~ ~x~cvt~d in duplleato and ori~inal fii~d with CIKIc Cirwit Cou~, and dupliut~ witb Tax Ass~or.) ,
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