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Declaration of Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
S1. IUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in accordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of Iylanaeeuan Nprt TnrS~T_
(City) (Stara)
and 1 resided at - 4~ North Maine _. However 1 have changed my domir3le
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since 11th day of
_ August 194, and 1 reside at 123 North 17ft+ Stre t
(Sheet and Number)
FORT NERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Honda.
pnsert 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.)
Bntering child is school
FILED AND RECORDED
ST. LUCIE COUNTY. FLA.
RECORD VCRIFIED
1820"73
'69 AUG 21 ANI 10:07
~~
~iOGER POITRkS
C1_ERK 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 LUCIE COUNTY, FLORIDA, permanently.
~.~
(Name)Mrs. JOan Ives
(Address)
Sworn+ig.and wbscribed before me this 2131 day of August , Iq 6Q
,;,..• ,.
... s' j
:~ .FORK CIRCI~ COURT Notary Public
_ .. ~ ~_
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13y = D.C. My Commiss'wn expires
(1'd~ .~ ... ~ in duplicate and original filed with Clerk Cirarif Court, and duplicate with Tax Aseeaor.)
aoolc179 ~cE1323
No. 13
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