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Oeclaration ot Domiclle and Citisenship ;
TO THE STATE AND COUNTY TAX ASSESSOR, ~
Sl. IUCiE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and
im m~formity with Chapter 222, Section 222.17, Flo~ida Statutes.
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1 was formerly a lega) resident of 11~asi _ _ Flori a
(City) (State)
and 1 resided at _?28a_S~lOb ~errd~e However I have changed my domiG~e
(Street and Number)
to and am and have been a bona fide reside~t of the State of Florida since Nevemhpr _ dey of
- . 19._..$~, and I reside at 19?~ ~~r.•a~ ~venn
(Street and Number)
FORT PIERCE, SAINT LUGIE 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 he~e any pertinent facts, such as sale of property or business, or relinquishment of employment
t
at former domicile, removal of family to new domicile, purchase of home, etc.)
Filing ior homeBtead ezenption -
FtLEG^Ac:~Q ~ECORO~L ~
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1 FURTHER CERTIFY that I wilt comply with al) other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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""e~ Wal r . Clay
(Address) _
Sworn to and subs~ribed }~efore me this 17 day of Febrnarg ,~q~0 .
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ROGER P.Qt ,~~t ;
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CLERK.ClIN~II~~1J ' ,q Notary Public
By ~ Y+'` U- D.C. My Commission expires ~
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(To bs exscuhd~in..t~apfiqi~~si+d ori~inal filsd wjtb CIKIc Grwit Court, and dupl~ut~ with Tax Ass~ssor.) ~
. . . aoo~ ~~2 PA~2932 ~
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