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Declaration ot Domicife and Citizenship 158190
TO THE STATE AND COUNTY TAX ASSESSOR, ~
51. LUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in aooordance and ~
in confo~mity with Chapter 222, Section 222.17, Florida Statutes. .
I was forme~ly a legal resident of 1~+lount Irlorria ldlM Yor~ ~
. (City) (State)
and 1 resided at ~lurrsJ~ Hi11~Nuraes• Rl8idetlCe . However I have changed my domic,ile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since llth day of ~
wuQUSt ,~9.~Q, and I ~es~de ar 118 N.B. Jaradain Rd. Zi~er Parl~
(Street and Number) • • U le
fORT PIERCE, SAINT LUCIE COUNTY, FLORIDA I
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Horida. ~
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(Insert here any pertinent facts, such as sale of property or busineu, 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. ~~C~E COUNTY, F(.Q,
"fl.•r' V=Rlhlf'[,
1~8190 ~
'7D ~'~~d I 2 Pf+l ~ 3: 5 ~ '
~ - -F ~'01T
CLERK CiRr
..UIT COURT
1 FURTHER CERTIFY that I will oomply with all other requirements of a leyal resident of thia State.
1 FURTHER CERTIFY that I have no intention to return to my former domiCile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, perma~ently.
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' R RBIF
(Name)
f;: ~:z 118 N.B. _Tsrdain Road, River Park
~~'.t ' (Address)
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•n ~Sv~ott~ tacahif ~bscribed before me this 1~_ day of _Tilau8i3( , ~q ?0 ,
. . s. ~ ~
:a . ~
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~i1` C RT Notary Public
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By ' D.C. My Gommission expires
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lTo b~ ~x~cvt~d in dupliut~ and oripinal filed with Cl~k Grcuit Court, and dupliuh with Tan A:sa~or.)
T ,3 _ BOOK1~2 PACE 5~1
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