HomeMy WebLinkAbout0912. ~g~~7y
Declaration of Domicile and Citlsenship
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this dsy in aoaordarxe and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of ChiCa~o _ - Ille
(City) (Stets)
14765 SO• Nenard However 1 have changed my domicile
and 1 resided at -
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ~~ day of
r! ~ _ 19~2~., and I reside at ~~y7 So. U•S• ~~
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Honda.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
Bstablishilag residence and citizenship is the State of Florida
FILED AND RECORDED
ST, LUCIE COUNTY, FLA•
~ECOF?D VERIFIED
'69 AUG 3 81`?"?'4
~ 8:15
'~O~r'01T
CLERK CIRCUIT COURT
1 FURTHER CERTIFY that 1 will comply with all other requirements of a legal resident of this State.
1 FURTHER CERTIFY that 1 have no intention to return to my former domiCjle, and I intend to remain in FORT
PIERCE, SAINT t.UCIE COUNTY, FLORIDA, permanently.
f~
(Name) Raytiand B Yan erten s
r.
1~ , .S . ~•._f _ _
-_'.; ;:~t~C3 ~'•: (Address) Eileen R. Van 1+leerten,
'~°°'° ~' tp, and subscribed before me this ~ day of 19---~
.. ~.
.%~~~~~,
;.°.%:; ~~~iRCUR COURT Notary Public
~~•+~~
w
ay
D.C. My Commission expires
(To bo exewtad in duplicate and original Bled with Cleric Cirwit Court, and duplicate with Tax Assssior.)
~~
aoo~ 179 ~~ ys~