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Declaration ot Domtcile a~d Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
51. LUCIE COUNTY, FIORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and
in conformity wiPh Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a legal resident of _ Si11?is. Illinoia _
• (City) (State)
1018 1Qth 3treet
and 1 resided at However 1 have changed my domic.ile
(Street and Number)
b and am and have been a bona fide resident of the State of Florida since !T~e - - day of
. 19~5_, and I reside at 160~--Colo~lia Qs'~ -
(Street and Number)
FORT PIERCE, SAiNT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual tegal residence and domitile 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.)
Ldod~ts 8atablisLins r~~id~nce
FILED AND REN~Y
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1 Ft1RTHER CERTIFY that I will comply with al) other requirements of a leyal resident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domicjle, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. `
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(Name) g~~ g~e~l~r
(Address)
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',r Swol~~l0 4tTd suburibed before me this 1~ day of ~ , h9 70.
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: ~ - - `'~x~RCWT COURT Notary Public
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By • ~ D.C. My Commission expires
(To bs executsd in dupliute and ori~inal filsd with Clerlc Grcuit Cour~, and duplicsh with Tax Asassor.)
BOOK 104 PACE 20~8
No. 1 ~
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