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Declaration ot Domicile and Citizensf~ip ;
165553 }t
TO THE STATE AND COUNTY TAX ASSESSOR, • [
Sl. LUCIE COUNTY, FIORIDA:
This is my declaration of Oomicile a~d Citizenship in the State of Florida that 1 am filing this day in acoordance and
in conformiy with Chapter 222, Section 222.17, Florida Stetutes.
1 was formerly a legal resident of Preehold N~1~?_~Ter_ae~? _
(City) (State)
Silvers Road ~~„~ever I havecha m domiCl~e
and I ~esided at - n9~ Y
(Street and Number) t
~
to and am and have been a bona fide resident of the State of Florida since lsth day of ~
August 6~ ?04 Az~lea A~?~r~!~ ;
_ _ , 19 and I reside at ,
(Street a~d Numbe~) ~
FORT PIERCE, 3AINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence a~d domicile in the State of Horida. E
;
(Inseri here any pe~tinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
HOMESTEA?D PURPOSES
ST~~E~ AN~ RfCO
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~n~E ~DUNTY FlA.
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CLE-R'''c r; %.tj'TR~S
' K CtRCUIT COURT
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I FURTHER GERTIFY that 1 will comply with all other requirements of a legal resident of this Stab. ~
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I FURTHER CERTIFY that I have no intention to retum to my former domicl~e, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
A
C 61 ~_~_c~,
(Name) eIl . r0
~ ?04 Azalea Ave., Ft.Pierce,Fia. 4
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v`~...~Q U¢ ~ . (Address)
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" ? ~ = 26th March 6S
~"=~~r~6~ a~ subscribed before me this day of , 19 .
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QIRCUIT COURT Notary Public ;
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gy D.C. My Gommission expires ;
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1To b~ ~x~cutrd in duplicab and oriyinsl fil~d with CIKIc Grarit Court, and duplicat~ with Tax Ass~ssor.)
, 600K ~~1 PACE 243
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