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Declaration of Domicile and Citizenship
TO THE STATE AN~ COUNTY TAX ASS~SSOR,
Sl. lUC1E COUNTY, FIORIDA:
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 ~22.17, Florida Statutes.
I v~ras forme~ly a legal resident of - Hpll~00d BeiGh F1z_ _
(Ciy) (State) -
-a _
and I resided at 1504 S~ Surf Rd. 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 1St day of
_ November , ~q 69 ~ and 1 reside at ~ 715 BiRancho Dr.
(Street and Number)
FORT PIERCE, 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 Horida.
(Insert here any pertinent fads, such as sale of property or business, or relinquishment of employment
at fo~mer domicile, removal of family to new domicile, purchase of home etc.)
(Homestead Bxemption) ±
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F1LED AND RECOROEO ~
S7. LUCIE COUNTY. FLA. :
F?~.CC!~n VERl=~cp
~8863'7 -
'70 JAN 21 AM 10: 51
;
~ ::o::r_ ~ ~-o~T~c,s
~ CLERK CIr~CU1T COURT~
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I FURTHER CERTIFY that 1 will aomply with all othe~ requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domiCi~e, and I intend to remain in FORT
PIERCE, SAINT IUCIE CQUNTY, FLORIDA, permanently. GEOIge :$Sqll ?
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~ , . ~s?r.. (Na e)
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~ ' ?15 Bl Rancho Rd.
~ - - . ~
~ . . sy~ _ (Address) {
~ : . , ~ _ ~
~Sw~th~~
~rnd suburibed before me this 21gt day of .Ianuary , tq~. ~
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~ '`_L',,_~..:.`'~
~„`,~,1~~ ~
~ ~ ~ ROGER POITRAS
CIRCUIT COUR Notary Public
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By D.C. My Commission expires
~ (To M exscut~d in dupliuf~ and ori~inal fil~d with q~rlc Ctrcu~t Court, snd duplicat~ with Tax Ass~ssor.)
~ b0~!(1~~ PACE1~c~~
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