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Declaration ot Domicile and Citisenship
TO THE STATE AND COUNTY TAX ASSE550R,
51. LUCIE ~OUNTY, FLORIDA:
This is my declaration of Domicile a~d Citizenship in the State of Florida that 1 am filing this day in accordance and
in conformity with Chapter 222, Section 222.17, Florida Stetutes.
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I was formerly a legal resident of AL1bLU`II N• y• _ $
. (City) (State) ~
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Park Place ~
and I resided at 1~ _ However 1 have changed my domiGle ;
(Sireet and Number) i
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to and am and have been a bona fide ~esident of the State of Florida since ~til _12 _ day of
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, t9?~, and 1 reside at i50~ Georgia Avenue
(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 ihe State of Florida.
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(Insert here any pertinent fads, such as sale of property or business, or relinquishment of employment ~
at former domicile, removal of family to new domicile, purchase of home, etc.)
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~ I FURTHER CERTIFY that I will comply with all other requirements of a(egal resident of this State.
~ I FURTHER CERTIFY ihat 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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~ ~ (Name) Gilbert E Cullen
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~ ~,$~orn.t~:!arid.subscribed before me this 14 day of ApTil 19 ;
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~ , ~t-_ `~~~,~~OURT Notary Public
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~ By D.C. My Commission expires
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_ (To b~ executed in duplicate snd originsl ~iled with Clerk Grcuit Courf, snd dupliwt~ with Tax Ass~ssor.~
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