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Declaration ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
51. IUCiE ~OUNTY, FIORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in actordance and
in conformiry with Chapte~ 222, Section 222.17, Florida Statutes.
1 was formerly a legal resident of -Diari~--- GeorQia
~C;ty~ (State)
and 1 resided at ____CQes:~81_ TrB; ~ er Parlc _ However 1 have changed my domic.ile
(Street and Number)
to and am and have been a bona fide ~esident of the State of Florida sinte ~Febrnar5?.31 _ day of
, 19~II-, and 1 reside at ~~dY Lane Cottages go. Fed. AiQ wav
' (~treet and Number)
fORT PIERCE, SAINT tUC1E COUNTY, FLORIDA -
and this statement is to be taken as my declaration of cit~zenship, actual lega) residence and domicile in the State of Horida. ~
(Inse~t here any pertinent fads, such as sale of property or busineu, or relinquishment of employment ~
at former domicile, removal of family to new domicile, purchase of home, etc.)
Entering child in school David, James, Pae and Panla Rich
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FILEO AND REC~RDED'
ST. IUCiE COUNTY. FLA.
.=R1~'E~J -
190195
'70 FEB 23 PM 2:2
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CLERK C~~C~IT COURT
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~ I FURTHER CERT1Flf that 1 will o~mply with al) other ~equirements of a legal resident of this State.
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~ I FURTHER CERTIFY that I have no intention to return to my former domitjle, and 1 intend to remain in fORT
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~ oIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ (Name) David $ich
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. Sworn to;erul,a~scribed before me this Z*~ day of FRh*~~ - , 19_?11__.
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Nota Public
` ~CL#RK CIRCUII;:
CO~tT~` ry
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ey ~ ~ " D.C. My Commission expires
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~ (To be executed i~ duplicate snd orisinal ~iled with Clnic Circuit Court, and dupliut~ with Tax Assesw?.)
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