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~777~~
Daclaration ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
Si. IUCIE ~OUNTY, FIORIDA:
This is my declaration of ~omicile and Citizenship in ths Stats of Florida that 1 am filiny this day in acoordanoe and
in confo.mity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of Sapvilie H!M YOIt
(Ciy) (Sta»)
15~ Loop Dri~e
and 1 resided at . However I have changed my domic~le
(Street and Number)
ro and am and have been a bona fide resident of the Stste of Florida since ~Ce~~= 10 day of
880 Airoao Bl~d.
, 196a , and 1 reside at
(Street and Number)
FORT W~CE, SAINT LIKIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actuaf lega) residence and domitile in the State of Horida.
(Insert here any pertine~t facts, such as sale of property or business, or ~elinquishment of employment
at formcr domicile, removal of family to new domicile, purchase of home, etc.)
Bstabiishing residence
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I FURTHER CEftTIFY that I will eomply wiffi all other requiremenh of a leyal residenf of this Stste.
1 FURTHER CERTIFY that 1 have no intention to retum to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently. .
~ Q/l~c-~Yl ~ QA.'u-'Y1
~ (Name) llsrioa wsrrea
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~ ~ 1~4~d G~.~i~-a? o~,~. ,(t.cc,eJ
(Address)
Sworn to and subsuibed before me this lst day of - ~t , 19~~.. '
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,~OOMl,TO1TRAS ~
¢iR~. C`pNRT Notary Public
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8y D.C. My Commiuion expires
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