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D~cla~atlo~ ot DomiQil• and Cltl:~nship
TO THE STATE ANO ~OUNTY TAX ASSESSOR,
Sl. WCIE COUNTY, FIORIDA:
This is my declaratio~ of Domicile and Gitizenship in th~ State of Florida that i sm filinq this dsy in sooord~nce ar?d
~n oonformity with Chapter 222, Section 222,17, Florida Statute:.
I was formerly a legal resident of ~_~jR~; {~~l l. =~y~a _
(Cty) (Stat~)
and I resided at _~Cot~ Cap1~tl~uo . However I have chanyed my domi~ile
. (Strset and Number)
to and am and have been a bona fide resident of the Ststs of Florida since J~~ 1 day of ~
_ , t9 , And ~ reside at ~Qie Comts~ Clnb p~r~ g~, Lnoie t
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- (Sheet and Number)
!`0 Pi~rce. ~'la. I
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA ~
and this stateme~t is to be. taken as my declaration of citizenship, actual legal residenoe and domicile in ths State of Horida.
(Insert here any pertinent facts, such as sale of property or busineu, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.) ~
Brno~ Santschi
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ST.RECO~RD VEqN'~Y~'~ ~
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ROGCR F'p~TRl~g
CLERK CIRCUIT COURT,j ~
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I FURTHER CHtTIFY that I will oomply wlth all other requirements of a le~al resldent of this StaM.
1 FURTHER CERTIFY that I have no intention to return to my former icj and I i to remain in fORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. -
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- - _ (Name) . 3v?tae6i
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(Address)
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Svrorn.to and subscribed before me thi: lo dsy of ~p~ , 19_IO.. :
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B~''f D.C. My Commission sxpires €
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~ ~ . a~K 186 i46~ ~
No. 13
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