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~ De~laration ot Don~icile and Citizenship .
~
TO THE STATE AND COUNTY TAX ASSESSOR, -
Sj. lUC1E COUNTY, FLORI~A:
:
This is my declaration of Domicile a~d Gitizenship in the State of Florida that 1 am filing this day in aaoordance and
in oonformiy with Chapter 222, Section 222.17, Florid~-S~tutes.
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I was formerly a legal resident of ~~9u . ~ O$IO
~~iry) (State) ~
and 1 ~eaided,at Bt. 4 , . However 1 have chan~ed my domicjle
(Street a~d Number)
to and am and have been a bona fide resident of the State of Fiorida since day of
~
_ Jul~ _ , i9 68 , and I.reside at 1403 Ponoe Ds 7~eon Prado
(Street s~d Number)
FORT PIEItCE, SAINT LUCIE COUNTY, RORIDA _
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Horida.
(In ~~t here any pertinent fads, sucFi as sale of property or business, or relinquishment of employment
at former domicile, rem~Dval of family to new domicite, purchase of home, etc.) ~
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D$CI~ABIBa BBSIDSBCY
. ^ aECO~o~o _ '
F~L'LUCIED ~V~~~Y:
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I FURTHER CfRTIFY that I will oomply with al) other requirernents of a(esel reaident of this State.
I FURTHER CERTIFY that I have no intention to retum to my former domicjle, and 1 intend to remain in FORT
PIERCE, S~ lUC1E COUNTY, FLORIDA, permanently. ~
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~ L~i S~~H
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(~4ddress)
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~ Swom to and subsuibed before me thi~ ~th day of jIIa~~ 19 6g •
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ROGER ~ 'v~ .•~~t~.uL -.i:
I R COU ; f~~? ~~fn , ~!'~~t Notary Pubfic
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gy = ~ : f• _ My Commission expires
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(To b~ ~x~aihd in dupli aml~ofi~.. f~Hid••~iirhh C{~Ic qra~it Cowf, and dvplicat~ wifh Tax A~or.)
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