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Declarution ot Dornicile and Citize~ship ~`g,~ r '
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TO THE STATE AND COUNTY TAX ASSESSOR,
51. LUCIE COUNTY, FLORiDA: i
This is my decla~ation 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, Ffo~ida Statutes.
I was fo~merly a legal residen! of _ - . ~~i~~~~ ~ -
(C~ty) (State)
and I resided at ' However 1 have changed my domicjle
(Street and Number) ~
to and am and have been a bona fide resident of the State of Florida since day of
, 1 , and I reside at ~
t t and Number)
F
FORT PIERCE, SAINT LUCIE COUNTIf, FLORlDA
and this stateme~t is to be taken as my declaration of citizenship, actual legal residence a~d domicile in the State of Hotida. ~
(Insert here any pertinent fads, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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FILED AND RECORDEO'
ST. LUCIE COUNTY. FLA.
RFCQRO VER1~'IED
1~3`756:~
; '69 OEC 29 AMI 10:29
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' FOG~ R r01TR~S
~ CLERK C{RCUIT COURT:
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I FURTHER CERTIFY that I will comply with all other requirements of a leyal resident of this State.
~ I FURTHER CERTIFY that I have no intention to return to my former domiti~e, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
~ Cl " ~.:L~•.-.o-'sti ~
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~ (Name)~ ~/~~zLDy? 4
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SWOrn fo.4'r~#,aubscribed before me this day of , 19 -
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~ . CtIRK C CO RT Notary Public
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~ By D.C. My Commission expires
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(T b~ ~xecut~d in dupliut~ and oripinal filsd with qerk Circuit Cour1, a~d duplieat~ witb Tax Ass~sor.)
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