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DeclarAtion ot Domi~il• a~d Citis~nship
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE ~OUNTY, FIORIDA:
This ia my declaration of Domicile and Citizsnship in the State of Florida that I am filin~ this day in aaoordanos and
in oonformity with Chapter 222, Settio~ 222.17, Florida Statutes.
I was formerly a legal resident of ~1i
(City) ~StaM)
and 1 resided at ~~~ii Pwl• Street . However I have changsd my domidle
(Street and Number)
to and am and heve been a bona fide msident of the State of Fiorida sinoe ~st day of
- - , 19 d~ , and I ~eside at 60~ Ha~ptaa Flaoe
(Street snd Numbe~)
~ORT PIERCE, SAINT LUC~E COUN~'Y, RORIDA
and this statement is to be taken as my declaration of citizenship, attual legal ~esidenos and domiale in the State of Horida.
(insert here any pertinent facts, such as sale of property or business, or relinquishment of empbyment
at former domicile, removal of family to new domicile, pu~chase of home, et~c.)
~aieriat ~ild ia p~blie so4ool
Stieriar I~e Ws~r~itt .
-FtLEO AND RECOR0~0~ ,
ST.R~
C~RD YERIF EO~~
1930~2
'TO MAY 6 PM 3:31 s
+~~V~
ROGE~ ~017R~?S
CLERK CIRCUIT COURTr
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I FURTHER C6RTIFlf that 1 will oomply witfi al) other requlrerr~nri of a lepal r~ident of this State.
I FURTHER CERTIFY that I have no intention to retum to my former domicjle, and I intend to remain in FORY
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
. V ~
~a""°~ dr~• Iltrtitt .
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~ (Address)
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~ ~ _ _ TO
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f ibed before me this ~ day of ~ , 19 .
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~ - ? ~i-•:=,, " 3:~ i+~t~ Publk
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~ By _ • D.C. My Gommission expi~es
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~ lTo bi "t~iiaM~d in dup1icaN and o~inal Al~d with Ctwlc Cira~i? Cou~R, and dupliat~ wi1b Tax At~ora
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~ ,~.13 ~~184 ~1243
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