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Declar~tlon ot Domicile and Citizenship 1~2~~ ;
2
TO THE STATE AND COUNTY TAX ASSESSOR, ~
s ~
51. IUCIE COUNTY, FLORIDA: ~ ~
This is my decfaration of Domicile and Citizenship in the State of Florida that ! am filing this dry in accordance and
in conformity with Chapte~ 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of At1a21t~C NOI'th C8Y'o13II8 _
(Ciy) (State)
&eneral Delivery
and 1 resided at _ _ - However I have changed my domicjle
~ (Street and Number) ~
to and am and have been a bona fide resident of the State of Florida since _ 15 day of ~
d
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~HLCh 19~_, and I retide at nOCEAN SCAIrLOPS 1NC. POBX 3549 ~ ~
(Street and Number)
FORT PIERCE, SAINT lUC1E COUNTY, FLORIDA
and this statement is to be taken as my decla~ation of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment '
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at former domicile, removal of family to new domicile, purchase of home, etc.) ~
RILED AND RECORD~~S ,
Establishing residence ST.R
UCORD ~ER FYEbLA:~
' 192142
'TO APR t 4 AM! I I: 33 ~
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j r<C~ ~E~; i~047RkS '
f CLERK CIRCUIT COURT.~ ~
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~ I FURTHER CERTIFY that 1 will comply with all other requirements of a legal resident of this State.
- ~ URFHER CERTIFY that I have no iniention to return to my former domiGle, and I intend to remain in FORT ~
-
PIE(t~~'~ ' ~~CIE COUNTY, FLORIDA, permanently. ~
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~ _ :.`r. L't,+ ~~i , _ LL/1~ , #
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~ . o • - (Name) ~
~ ~ _ ~ . ~ c: ~ = Randolph Mason ~
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~ , . ,'C;''=' 7;z~~;`~~ (Address) ~
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~ Swom to and subscribed before me this 14th day of April ~ ~~q7~
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~ ROGER POITRAS ~
K CIRCUIT COURT Notary Public
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't By D.C. My Commission expires
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(To be executed in duplicate and originsl filsd with Cl~rk Circun Court, snd dupliuM with Tax Ass~s~.)
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BOOK 10~ PALE ~5 '
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