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O~aOa~atlon ~ Oo~iail~ aml Cltt=~nship -
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TO THE STAtE ANC COUNTY TAX ASSESSOR, ~
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Sl.~ lUC1E COUNTY. FLORI~A: ~
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This is my declaration of ~omicile and Cit~z~nthip in th~ Stat~ of florida that I am filinq this day in aa~da~os •~d
in conformity with Chaptet 222, Sectio~ ?22.17, Florida Statutes.
I was fo?merly a teyal ~eside~t of --_____-~81rh8oen J• - ,
(City) (Sta»)
64 Qilleepie Ave. ~
end I resided at However I have changed my domitile
(Sneet and Number) ~
to and am and have been a bona fide resident of the State of Florida since ______~rah __6__ ~ day of
- ~ , 19?~. anii 1 resjde at 3098 3S Pi118 Yglley St]~eet
Port St I.uCi~treet and Number)
FORT !'IERCE, SAINT LUCIE COUNTY, RORIDA ~
and this stateme~t is to be take~ as my detlarotion of citizenship, actual legal rasidence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or busineu, or relinquishment of employment
at formar domicile, removal of family to new domicile, purchase of home, ett.)
Betablishing resideaay and homeatead ezemption purposes
FILeO AND RECORDED'
ST. LUCIE COUNTY. FLA.
RFCORt~ v£R~Ft~D
19`78~~ _ .
- '70 SEP I PN 12: 09 ~ -
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F:OGE?~ r 0! ~ RAS ~
I - CLERK CIRCUIT COURT
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I FURTHER CERTIFY thst 1 will oomply with all other requirements of a le~al resident of thi: State.
I fURTHER CERTIfY that I have no intention to retum to my former domiCile, and I intend to remain in i~A~`-
..~E~SAINT LUCIE COUNTY, FLORIDA, permaneMly. .
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(Name) C emeIIt A. BT y, Jr
r~~ (Address)
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.Swqrp'~'i,(1~l~bs~ibed before me this 1st day of Septembe2' , 197~ .
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- ~ ~ - Notary Public
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6y ~ D.~. . My Gommission expires
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(To b~ ~x~enNd in ~ and oei~inal Al~d wilh CIKk Ci~c~it Cow~, and dvplicaN wilh Tax Aawe~a
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