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DeClaratio~ of Don~icfle a~d Cttizanship ~
TO THE STATE AN~ COUNTY TAX ASSESSOR, •
Sl. LUCIE COUNTY, FIORIDA:
This is my decla~ation of Qomicile and ~itizenship in the State of Florida that I am filing this day in aooordanoe and
in tonformiy with Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a legal resident of Ni~ra Falls Neri York ~
(City) (State)
and I resided at 2~7g 01PgiZ118 AVe2]Lie _ ~~„~ever 1 have changed my domidle
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since Oetober 1 day of
_ , 19
6~., and 1 ~eside at ~ 404 Juanita Avenue
(Street and Number)
FORT PIERCE, ~AINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Horida.
(Inse~t here any pe~tinent facts, such as sale of property or busineu, w relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
Purcheaed home at 1404 Juanita Avenue
(will move in first ot' Deaember)
Preeent mailing addrees: 610 No. 23rd Street
- o/o Riohard Bellamy
F1LED AND RECORDED
yT, lUC1E COU~:TY. FLA.
t~_ ,,.~;,R VE:z;-~:
~ ~ 18544`7
~ '~9 h0~! 12 PM l2:22~
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' :t=? "r'~~I~TR:,S
~ CLER4C CiF'tCUIT COURT
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1 FURTHER CfRTIFY that I will oomply with all other requirements of a leysl resident of this State.
I FURTHER CERTIFY that I have no intention to retum to my former domiti~e, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
~ t/ .
• (Nams) Heary ~'alover
~ ~?.CLcv.a. ~~N~4'kE~
--(+~e~~} Oeaiae Glover
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. Swo~ ?b=a~ild,3ub~ttibed before me this day of , 19 .
. - . .
,ItoGHt po~iuis . ~ i
i° tiERK ClRCl~1~=.COURT Notary Public ~
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By ~ D.C. My Commission expires
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(To b~ ~x~cvt~d in dupliuts and ori~inal fil~d with CINIc Circuit Cowt, and duplicat~ wHh Tax As~or.)
d00K~~ PAbt~~~
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