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~ Declaration ot Domicile a~d Citizenshlp
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TO THE STATE AND COUNTY TAX ASSESSOR,
~ Sl. IUCIE COUNTY, FLORIDA: j
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This is my declarati~n of Domicile and Citizenship in the State of Florida that I am fili this da }
~ ng y in acco~dance and
~ ~n confo~mity with Chapter 222, Section 222.17, Florida Statutes.
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( 1 was formerly a lega) resident of --~8~a~~- ^^Qhip _
' tCiy) (~tate)
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and I resided at However 1 have changed my domicilc
(Street and Numbe~) -
~ ro and am-and have been a bona fide ~eside~t of the State of Florida since ___18~--- day ot
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--4C~4~L~~_ 19
6~, and 1 reside at _ 1Q?1 R~val palm Drivw
(Str;.~et and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this sfatement is to be taken as my declaration of citizenship, actuat legai residence and domicile in the State of Horida. t
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(Insert here any pertinent fatts, such as sale of properfy or business, or relinquishment of employment ~
at former domicile, removal of family to new domicile, purchase of home, etc.) ;
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~ Sold property and businese in Ohio. ~
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Establish Reeidency to claim homeatesd ezemption
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I FURTHER CERTIFY that I will oomply with al) other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domiCile, and I intend to remain in FORT '
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ (Name) JOhn E..-L`OlesBri ~
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(A d~ess) ~
Sworn to and subscribed before me this day of _ FebPUary , ~q~__
ROGER POtTRAS . , .
CLERI~ C(~~t11~:C0 RT~ Notary Public
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BY D.C. My Commission expires _
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(To b~ ~X~cuhd. in duplicate and orwpin~ai filsd with Cl~rlc Grw+t Court, snd duplicat~ with Tax Ass~ssor.)
~ ~ ~ 8~170 ~i~g9
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