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O~alal'~t10A Ot OOml~til~ a1111 ~:itisN~ilap
TO TME StATE M10 COUNiY tAX ASSESSOR, _~.~~7~~
Sl. ltJC1E COUNT`!. FtORiOA: .
Thi~ is my daclu~tio~ of Oomicil~ ~~d Citl~+ship in fh~ St~t~ of Florida that 1 am filinp lhi~ day in aooonlana ~nd
in oonformity with CfiapNt ~22, S~ttbn Z4Z.17, ~ida Statubs. .
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1 wu~ formKly ~ Ip~l rosidMf of ~/l.d.~.~l~i~/ ~N~y~~•~~~•,1----
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and 1 nsid~d ~t ~/4~0 ~//G . HowwK 1 haw chat~q~c! my domidl~
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ro•nd ~m and haw b.M a bona fid~ nsid.nt of tM Staa af Horida si~ --L~-L~ 70 day of
19 , and I nsid~ N ~.t~. ~ LS.~.Z •r~ll?.t~1t/ r_
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l~ORT ~ SAMlT t11C1E OOUNTY, RORpA '
and this ~tatement is ro b~ takan as my decla~ation of ciH~nship, actval ipal r~sid~na and domkil~ in th~ Shi~ o.f Horida.
pnsert hers any pKtin~+t fads, such as sal~ of property or businas. or nii~quishmant of ~+nploymsnt
at fame~ domkite, rernovd of family b naw danidle, purchas~ of homs, ~ic.)
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1 RJRTHER CHtTIFY Mut 1 will aomply with all ott~ nquinm~?is of a Ipa! ~uid~nt of fhb Stat~.
1 RIRTHER CERTIFY that 1 have no intention to return to my former domiGie, a~d 1 intend to r~main in fORT
PIERCE, SAINT UKIE COUNTY, RORIDA, p~rmanantly.
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d~r_ 0 C. My Ganmis~ion ~xpira
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