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O~claratio~ ot Domicii~ a~d Citis~nship
TO THE STATE AND COUNTY TAX ASSESSOR, '
1'73~i32
Sl. U1CIE COUNTIf. FIORIDA:
This i: my declaration of Damicile and Citi~nship In ths State of Florida that I am filin~ lhit day in sooordano~ and
in aonformity with Chapter 222. Sattio~ 222.17, florida Statutes.
I was formsriy a Ipal rosid~r~t of • 7/!~'~ '
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and 1 nsidsd at . Hovvwer 1 have charqsd my domidl~
(StnN and Number)
ro and am and have been a bo~a fide rosident of the Stsh of Norida sinoe - day of
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, ~9~, a~d ~ ~ide ~ ~ .t .1' /g a ~GS' ~
~~nd Nurr+ber) C
l~ORT lIQCE, S~AfNT LtlCIE COUNTY, RORIDA
a~d this statement is to be taken as my deda~ation of citi~enship, actust layal residenoe and domiale in the State of Horida.
(Insert hers any pe~tinent facts, such as sale of propsry or business, or relinquishment of employmsnt ~
at former domicile, r~emoval of family to new domicile, purchase of horne, etc.)
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~ 1 RJR'THER G~tTiFY tfi~t I wlll oomply with all otF~ roqvin~rMnis of a lepal rosidsnt of this Stah.
1 FURTHER CERTIFY that I have no intention to retum to my former domic,ile, a~d 1 intend to remain in FORT
PlERCE, SAlNT U1CIE COUNTY, FLORIDA, permanently.
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