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Declaratio~ ot Domicii~ and Cittzenship
TO THE STATE AND COUNTY TAX ASSESSOR, ;
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Sl. IUCIE COUNTY, FLORiDA: ~
This +s my declaration of Dom~cile and Citizenship in the State of Florida that I am filing this day in accordance a~d ~
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~n conformity with Chapte? 222, Section ?22.17, Florida Statutes.
I was formerly a legal resident of ~ Joliet Ill
(City) (State)
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and I resided at 221 CsreenYil~r CitCl! _ _ Nowever 1 have changed my domicjle s
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(Street and Number) =
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ro and am and have been a bona fide resident of the State of Florida since pQt~ yg day of ?
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, 19_.TO , an~ I res~de at ~.91 I~1c~huratl._ Drfve =Port St~ ~,u~~e_
(Street and Number)
FdRT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my decfaration of citizenship, actual legal residence and domicile in the State of Florida.
(Inser~ here any pertine~t facts, such as sale of property or business, Qr relinquishment ot emp!oyment
at former domicile, removal of family to new ~~micile, purchase of home, etc.)
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flntering child in public sohool
Lori Brere~on
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u I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
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~ I FURTHER CERTIFY that I have no intention to return to . ,icjle, and I intend to main in FORT
~ PIERCE, SAINT LUGE COUNTY, FLORIDA, permanently. ~
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~ (Name) ~b~M F`• Brereton
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~ ~~i~OrA-rst.acid subscribed before me this __28th day of -__.D~t.nb~ i9~Q_. I
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~ ~y ~R COURT Notary Public
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F£ By . D.C. My Commission expires _
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~ (To b~ ~x~sut~d in duplicat~ and ori~inal ~il~d witb Clarlc Circuit Courf, and dupiicaN with Tax Ass~ssor.)
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~ ,3 aoaK18?' ~2828
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