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Declaration ot Domicile and Citizenship ;
t
,
TO THE STATE AND COUNTY TAX ASSESSOR, ;
S1. LUCIE GC~UNTY; Ft~RIDA• I
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of Ch1C8g0 I11.
(Ciry) (State)
and 1 resided at -~_-TQ 11~._BLiTtOII Pl. Howeve~ I have changed my domiCi~e ~
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since 8th day of
_ ____~Qaat- , 19~t~, and 1 reside at 617 Ash St. Rivet Park ~
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, ad~al legal residence a~d domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of propery or business, or relinquishment of employment (
:
at former domicile, removal of family to new domicile, purchase of home, etc.) ±
i
(Homestead Exemption)
FILED AND RECOROED` ;
ST. LUCIE COUNTY. FLA:
p~~~;~~,;~~~~.~9821 ~
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,
i 'TO FEB I 3 PM : Oy ~
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~ r_~ :.ot ; p:.s
€ CLERK CIRCUIT COURT;
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1 FURTHER CERTIFY that 1 will comply with all other requirements of a legal resident of this State.
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~ 1 FURTHER CERTIFY that 1 have no intention to return to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. R th M. Davis
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~ (Name)
~ ~
. qL_~
2 . ' , T'~Y.
° ,;.~.t,'~~~:..'1~,~'y~d_ - 617 Ash St. River Park
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.s '.`1: ~ ~*14~; ~~~~~~s, _ . (Address)
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. ~.F;3'-• r:, ( ~ Y ~ i^.
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~ - =~~;`;;.~y~ 3b;a~c~ subscribed before me this 13 th da of February ~ ~ q 70 ,
F'~ :~_~'~.`Y' -:;11 ^ ' - y ,
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:~~'y, ~~;~~~MQ~
, C111T COUR Notary Public
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~ ey D.C. My Commission expires ~
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°t (To be ~xscuhd in dupliuM and ori~inal filed wfth Cl~~lc Circuit Court, and dupliut~ witl~ Tax Ass~ssor.)
~ 0 R 18~ PAGE 2~~
~ BOOK
No. 13 -
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