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Docla~atio~ ot Domlcil~ ar~d Cltis~nshlp ~~,2~~,7 i
TO THE STATE AND GOUNTY TAX AS~SESSOR.
Si. U1CIE ~OUNTY, FLORIDA:
This is my declaration of Domicile and Citiz~nship in the State of Florida that 1 am filin~ this day in aooo~dana and
in aonformify with Chspter 222. Ssction Z24.17, Horida Statut~s.
I was formerly a le~al resident of ~ichigan Cit~I IIIdiBriet
(City) (Stah)
201 Birch-tree Ferm
snd 1 roslded at . HowevK i have d~s~psd my domk3le
(Stnet and Number)
ro and am and have bsen a bona fide resident of the State of Florida sinoe OCt. 1 dsy of
68 3016 Overbrook - S
, 19 , and I roside at ~!~~I~~~.,11tb
(Streat snd Number)
I~ORT ~IQC~, SAINT LUCIE COUNTY, I~LOR~A
and this statament is to be taken as my dectaration of citizenship, actual legal res'~denoe and domidle in ihs State of Horids. ~
pnsert hero any pertinent facts, such ss sale of property or business, or mlinquishment of employment ~
et former domicile, removal of family ro new domicile, purchase of home, etc.)
Proof oi Citizenahip and intent to file for homeetead eaemption.
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I fURTHER I~RTIFY that 1 will aomply with all othsr requin~r~enb of a lepal rosident of thb State.
I FURTHER CERTIFY that I have no intention to retum b my former domicjle, and I intend to mmain in FORT
PiERCE, SAINT LUCIE ~OUNTY, RORIDA, permanently.
~ Ms~,,,e) w r . o e on
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~ - ~ • ~ - ~ (~?ddress)
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- ~ • . 25th Ho~ember 68
"_Sv~~. io ind wbscribsd before m~ thi: day of 19 .
ROOtR /OITRAt
CLiRK C~CINT COURT Notsry Public
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by ~ C.C. My Gommission ~xpi~ ~
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