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Declaratian ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, ~
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51. IUCIE COUNTY, FIORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am fili~g this day in attordante and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of _~llsboret~? ~ N. C.
(Ciry) (State)
and I ~esided at p! 8~ Q~a However I have changed my domid~e
(Street and Numbe~)
to and am and have been a bona fide resident of the State of Florida since ~Y 21 day of
, t9
TO , and ~ reside a~ B+oute 3, Bos 461 ~t. Pisrce. ~la.
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNYY, RORlDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertine~t 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.)
Placins child in pablic aehool - Doa~na Fl~ry~ ~tar
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F~IED AND R
ST. LUC1E ECORDED
_ COUNTY. F~H.
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1 FURTHER CERTlFY that I witl comply with al) other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ (Nam Jre w.Oziotd
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~ (Address)
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~ Sworn to and=subscribed before me this ~ day of 1E4Y , 19 T~ .
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~ " ~ `RO~E'R~-1'QITRAS
~ C~ERlC tIRC[!~T CQURT Notary Public
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~ By : D.C. My Commission expires
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~ (Yo ~ nqcut~d in dupliute and original Rlsd with Cle~lc Urcuit Cou~t, and duplieat~ with Tax Ass~s~or.)
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~ ~a BOOK184 PAGE~2~
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