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Declaration ot Domicile and Citizenship ~.'~53
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TO THE STATE AND COUNTY TAX ASSESSOR,
51. lUC1E COUNTY, Fl6RIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filin~ this day in aooordanoe and
i~ oor~formity with Chapter 222, Section 222.17, Flo~ida Ststutes.
I was fo~merly a legal resident of Bi1t~L0!! Md.
(City) (State)
and 1 resided at _ 714 e1?!lbr00~ ROid ~ . However 1 have chanqed my domidla
(Street and Number)
to and am and have been a bona fide resident of the Stste of Florida since 10 !h day of
~,pril _ , i9 i9 , a~ i ~es;de at 3012 B~er~reen A~enue
(Street and Number)
FORT MHtCE, SAINT LUCIE COUNTY, FtORIDA
and this statement is to be taken as my declaration of citi=enship, actual legal residence and domicile in the State of Horida.
(Insert here any pertinent fads, such as sale of property or busineu, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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FILED AND RECORDEb=
ST. LUCIE COUNTY. FLA.
R~CORD VERI~IEb
~'79453
'~9 JUN 13 A~I I1: 41
hUGEP, r 0lTRAS ~
~ CLERK CIRCUIT COURT: ~
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i t
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1 FURTHER ~ERTIFY that 1 will oomply witfi all other requirements of a leyal resident of this State. ~
,
I FURTHER CERTIFY that I have no intention to return to my former domivle, and I intend to remain in FORT
PlERCE, SAINT LUCIE COUNTY, FLORIDA, permane~tly.
~~~2~~
. ~ ~i P~TRIC[ [i~flilBR
~ ~~~-~''f~:-. . (Nama)
.
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~ 5012 B~ergreen A~e. Pt. pierce
~ ~ ~ . , = ~ (Address)
~ , . . '
~ Sworn_to a•~~1'scribed ~efore me this 13 day of T~~~t , 19~4
~ ~ ' G
~ . ` ` I i•' ~ i ~ .
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CIRCUR COURT Notary Public
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gy ~ h"~- D.C. My Commiuion expires
~ ITo b~ ~x~cubd in duplicah and ori~inal fif~d wltb ClKk Grwit Cour1, and dvpli~at~ witl~ Tax As~ora
~ ~ R ~.7g PACE 511
800K
No. 13 . '
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