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O~claration ot Don~icil~ a~d Citiser~ship
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, FLORIDA:
This is my declaration of Oomicile and Citisenship in ths Staro of Horida that I am filinq ihis dey in aooorda~ot ~nd
i~ aonformity with ~hspter 2Z2, Saction 222.17, Florida Statutes.
I was fermerly a leqal rosident of ate~n~illf s• C•
Ki~Y) tSta»)
and 1 rasidad at 11J1 Mi~dt~c=f D=i~f . Howavar I have d?snysd my domWl~
(Street a~d Number)
ro and am and hsve been a bona fide resident of the State of Florida sinc~ 1=t day of
_?u~e , 19~_, and I reside at 1 03 Pa~~.s''t.
_ (Straet and Number)
iORT M~CE, SAINT LUCIE COUNiY, RORIDA
and this statement is to be taken as my declaratron of citizcnship, actual legal residenoe and domicile in fhe State of Horida.
(insert here any pertinent facts, such as sale of property or business, or refinqui:hment of empio~yn+ent
at former domicile, removal of family to _new domicile, purchase of home, etc.)
F{LED AND RECORDED_
' ST. LUCIE COUNTY. ~La.
RECQR~ VERIFIE
1'
~''6~"~' . 9
. '69 MAR 31 AM 10. 3
rO~~ER POITR~S
C~ERK CIRCUiT COURT
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f .
I FURTHER GfRTIFY that 1 will oomply with all other requireme~ts of a leyal resideM of thls State.
t FURTHER CERTIFY that I have no intention to retum to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. C~`~~
- ss~ Ts~
crva~~
iS03 Paber Ct.
- (flddress)
Sworn to and subsuibed before me this 31 it day of , 19_~.
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CiRCUR CO!!RT _ ' - - ~ ~ - - Notary Publk
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gy - ' i~~E: .My:Gommission sxpiras
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(Te b~ ~x~aM~d in duplicat~ and a~i~l:~iwi~' Cirah Cour~, and duplicah wilb Tax A~o~a
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