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Declaratlo~ ot Domicile and Citise~ship
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TO THE STATE AN~ COUNTY TAX ASSESSOR, {
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S1. IUCIE COUNTY, FLORIDA: ;
This is my deciaration of Uomicile a~d Citisenship in the State of Flotida that I am filing this day in aototdante and
in conformity with Chapter 222, Section 2?2.17, Flo~ide Statutes.
1 was formerly a legal resident of Qll~ena 1iL.~ ~*k
(Ciy) (State)
and 1 resided at _ 138-T$ Broo1[villw ~l~rd. Flowever I have chanqed my domicale
(Straet and Number)
ro and am and have been a bona fide tesident of the State of Florids sinte day of
, 19 , and I reside at 180 Eato~n Dti~n Prrt St I+nci!
(St~eet and Number)
FORT r1ERCE, SA1NT LUCIE COUNTY, ftORIDA
and this statement is to be taken as my declarotion of citizenship, actual legal residence and domicile in the State of Horida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
~.te~~ ~iia in ~tiiie ~.oi
ANp RECOR~ED`~--
?ha~a~ Cast~ FII.EU~~E ~OUN~• FLA• .
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KO'~E~ ` ~OURT]
C~ERK CIftCU1T
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I FURTHER CERTIFY that I will comply with all other requirement~ of a le~al resident of thi: State.
I FURTHER CERTIFY that~ 1 have no intention to retum to my former domiCile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
J ~ ~
(Name) Clar~
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~ ' ~ (Address)
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_ ....ir~~ 8 lt~ TO
°tSwo(ti to and subscribed befora me this _ day of , 19 .
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~~~OURT
..'-i.~f ~ .~ICI~i~CU1T Notary Public
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8y - ~ D.C. My Commiuion expi~es
~ (To b~ ~x~cuhd in dupliu~. and orianal fil.d whh Cl.rk Cirwk Court, and duplicat~ wiTh Tax As~or.)
~ ao6K ~84 ~~.3~
~ No. 13
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