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o.aiaraao~ a oo~aw• a~ c.~as.~s~
TO THE STATE AN~ COUNTY t/1X JISSESSOR, ' .
Sl. Ll1C1E COUNTY, FlOR1~A: ~
This is my declu~tio~ of Domitile and Cit~s~nship i~ th~ Stat~ of Horida that 1 am fili~p this day in aooorda~+o~ a~d
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~n conformily with Chapter 222. Settior? 222.17, Florida Statutes. `
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1 was formsrly a 1e9a1 reside~t of jtie~e1 ~is~isia _ ~
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end 1 ~esided at _.~Rt~ 14~_ ~ 11~ _ Howevet 1 have cha~+~ee! m~? donticile
(Straet and Number)
to a~d am and have been a bona fide ~esident of the State of Florida sinae __!h3L10 ~Y ~
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- _ 19_T0__, and 1 reside at ~A?~ ~v! ~?i~. 1?_tt.• ~ ~
(StreM and Number) -
• . S~. P+~rt 8t Lre i~
FORT M~CE, SAINT LUCIE COUNTY, I~LORIDA
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and this statement is to be taken as my declaratio~ of citize~ship, actual legal ~eside~te a~d domicile in the State of Horids_
(Insert hera any pertinent facts, such as sale of property or busi~ess, or relinqvishment of emplo~yme~t
at former doinicile, removal of family to new domicile, purchase of horne, etc.) ~
s~lliarin~ r~ai~ne~ !ar 1tw~~t~ s:t~p~i~a ad p~lia ~~ol ptrpoa~a.
~ Ft~EO ANO RECORfl~~ .
" _ gT. LUCIE ~cOU~T~ ~~t'A''
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1'9`~4 : 38 .
•TQ SE4 2 ~
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~LERK C1RCUt7 COURT
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1 fURTHER ~HtTIFY that 1 will oomply with all otl»~ nqulr~rrMnis of a{s~ai tesident of this State. _
I FURTHER CERTIFY that 1 have no intention b retum to my former domicjle, and 1 i~tend to remain in FOaT
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently.
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~ (A~ddress)
~ : ~;'t~p,ard subscribed before tne this ~ day of ~~~r 19 ~ . ;
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- a' C Notary Public
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8y.'' ~ O.C. IVIy C.onwnission expiros
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