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Declaration of Dorr~icfle and Citlzenship `
TO THE STATE ANO COUNTY TAX ASSESSOR. 'iS¢~7'~~
51. IUCiE COUNTY, FtOF~IDA:
1
This is my declaration of Oomicile and ~itizenship in the State of Flo~ida that 1 am filing thia day in aaordancs a~d ~
in oonformity with Chapter 222, Section 222.17, Florida Statutes. .
1 was formerly a legai resident of • -
(Ciy) (State)
and ! resided at !~_3 ~ Nowever I have cha m domidie ~
, n9ed Y ~
(Street and Numbe~) ~ }
ta and am and have been a bona fide ~esident of the State of Florida since day of i
9
w`'~ , 19~, and I reside at °2 "Z -
(Street snd Number)
FORT !lERCE, SAINT LUCIE COUNTY, FLORIOA
and ihis statement is to be taken as my declaratio~ of citizenship, actual legal residence and domicile in the Stste of Horid~.
(Insert here any pertinent facts, such as sale of property or busineu, or relinquishment of employment '
st former domicife, ~emoval of family to new domicile, purchase of home, etc.) I
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- FILEO ANQ RECORDED'
~ ~ ST. LUCtE COUNTY, FLA.
fZ~~ORO V=RI~a~D
- ~ 18494g
'69 OCT 28 PM ~t : y I'
' O . 1~[~ i' ~
~ CLERK CIRCUtr~'~S
j T COURT; .
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1 FURTHER CERTIFY that 1 will comply with all other requiremenri of s le~al resident of this State.
I FURTHER CERTIFY that I have no intention to retum to my former domic~le, and 1 intend to remain in FORT
PIERCE, SAINT UfC1E COUfVTIf, FLORIDA, permanently.
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~:ubscribed before me this day of , }
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R POITRAS ~
CIRCUIT COU Notary Public t
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8y D.C. My Commiuion expi~es
ITo b~ ~xecubd ie dupliesh and oripin~l fil~d wi1l~ Cl~k CircuM Cou~, snd duplkaN witk Tax At~a~orJ
BOOK 180 PA~2189
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