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Oeclaration ot Domicile and Citisenshi~
TO THE STATE AND COUNTY TAX ASSESSOR,
,
Sl. WCIE COUNTY, FIORIDA: ~ _ ~
I
This is my declaration of Domicile and Citizenship in the State of Florida tha~ I am filing this day in accordance and
im m~formity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of IridlSritONn _ _ Fla.
(City) (State)
and I resided at 3rd 8treet However 1 have ci~ar.ged my domiGile
~ (Street and Number)
to and am and have been a bona fide resident of the State of Florida since llth day of
_ _ Y8y___________ ,~9
67, and I reside at 2?08 South 27th _
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA
and ihis statement is to be taken as my declaratio~ of citizenship, actual legal residence and domicile in the State of Ftorida.
(Insert here any pertineni facts, such as sale of p~operty or busi~ess, or relinquishment of employ~nent
at former domicite, removal of family to new domicile, purchase of home, etc.)
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E$tablishing residence
FI~EO
AND
ST?
V~~?n ;
V~ T~Y FLA• -
,s -~~43g~?
' 8 FEB ~ 5'~ 10 : 3
9
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CLERK C?RCUIr ~D~R
T
,
I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of ihis State.
I FURTHER CERTIFY that I have no intention to return to my former domic,ile, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE_COUNTY, FLORIDA, permanently.
,;`a:,:::r:.,;f~~:.,,•~;. ~
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, , . • - : ~ (Name)
, . J. Bell
_ _ . . . ~ :
r. ~ t • ~Y _
. (Address)
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~'Sworn 1o and subscribed before me this 15~h day of Feb• ~ ~q fi8 .
ROGER POITRAS ~
CLERK CIRCU T COURT Notary Public
~ati:~.~,~~
By D.C. My Commission expires -
(To be executed i~ duptiute and original ~iled with Cltrk Grcuit Cour~, and dupliwN with Tax ~~vssor.)
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