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Oeciaratio~ ot Domicile and Citlsenship
TO THE STATE AND COUNTY TAX ASSESSOR;
Sl. IUCIE ~OUNTY, FIORIDA: ~
2C0433 , ;
,
This is my detlaration of Domitile and Citizenship in the State of Florida that 1 am filing this day in atcordante and ~
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formeily a legal resident of T~pE~ RANSAS .
(Ciy) (State)
. i
12 w. 13th. Street
and 1 resided at -__55._ However 1 havechanged my domiCile
(St~eet and Number)
ro and am and have been a bona fide reside~t of the State of Florida since __11~1 day of
_J~lly_ 19~~ , and I reside at _2110 COTt@z Blvl.
(Street and Number)
FORT PIERCE, SAINT WCIE COUNTY, RORIDA ~
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in ihe State of Flo~ida. '
(Insert here any pertinent ~fads, such as sale of property or business, or relinquishment of employment
at fo~mer domicile, removal of family to new domicile, purchase of home, etc.)
Hesidence .
i~
ui°ciF cowi~r ~i~. ~
. CLERRCC RCUI~ C~~tRt '
RfCORO YERIFIEp~.,.,~
No+r 1 I i i8 ~!!'TO
2C0433
~
;
- ;
1 RIRTHER CERTIFY that l will oomply with a!I other requirements of a le~al resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domitile, and I intend to remain in FORT
PIERCE, SAINT LUCfE COUNTY, FIORIDA, permanently.
L;c~~t-a..1''.~-,.Lt~_ .
~,.~~"t~u~~u~~"~~~~~ ALBERTA PA~1TI$
. J ~ ? f~i
.
~4 •..GG~`i~.~ (Name)
C~ ;
x~'~~~•~cGs,P~
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c; 4: 2110 Cortez Blvd. , Ft. Pierce, Fla.
. ~ 4y ~
~ . (Address) 33450
~~i ~,••..t=°C'':~•'~ :
Ge 2nd ~Tovember 70
~''~in~~ subsuibed before me this • day of . 19 •
~
Y~ _
ro~u?s
CLFRK CIRCUR COURT Notary Public
.
gy D.C. My Gommission expires
(To b~ rx~eubd in duplicah and ori~inal ~il~d with Cl~rk Ci~arif Carrf, •nd duplieafa with Tau A»~aor.)
eooKl8g P~ ~3
No. 13
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