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, Deciaration ot Domicile a~d Cttizenship ~s~
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TO THE STATE AND COUNTY TAX ASSESSOR,
51. IUCIE COUNTY, FIORI~A:
This is my declarotion of Domicile and Citizenship in the State of Florida that I am filir~q this day in aaoordance and i
in co~fo~mity with Chapter 222, Section 222.17. Florida Statutes. ~
_y
New Leno= I11 noie #
1 was formerly a legal ~esident of . ~
(Ciy) (State)
and I rosided at _ 815 $outh P1]cle Str9At _ However 1 have chanqed my domidle
(Street and Number)
ro and am and have been a bona fide resident of the State of Florida :ince J3i3.3Llet day of
_~l~__ , 19_6.8i, and 1 reside at
(Strest a~d umber)
FORT PIERCE, SAIN? LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Ho~ida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at fo~mer domicile, removal of family to ~ew domicile, purchase of home, ett.)
: (Sharpa) _
Bntering Dennie 11ade 81oe in 5th grade of
school. ,(b,
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I FURTHER CER7IFY thst 1 will aomply with all other requirement: of a le9al'~esident of thts State. i
t FURTHER CERTIFY that 1 have no intention to retum to my forme~ domicjle, and 1 intend to rernain in FORT
PIERCE, SAINT LUCIE COUNTY, fIORIDA, permanently. -
(Nsme) I~18 ~aeBloo
(Yre. Aillia~ H.)
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~L•' .Swqrn tq~ sub:c:ibed before me this ~th dsy of ~»~~At , 19~~.
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, . s ' ~ Notary Public
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~ : fy"~' O.C. My Commiuio++ expires
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.(To bi , tA d~pljcat~ aed ori~inal fil~d witb GKk Cira~t Co~rt, and duptkst~ witb Tuc Ats~ssora
~~173 P~ ;~47
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