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Oecl~~ation ot DorniCile a~d Citize~ship
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TO THE STATE AND COUNTY TAX ASSESSOR, 2C 0561
Sl. IUCIE COUNTY, FLORI~A~
This is my decla~ation of Oomicile and Citize~ship in the Stete of Florida that 1 am filing this day i~ accordence and
~n co~formity with Chapter 222, Section ?22.17, Florida Statutes. . ~
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I was forme~ly a legal resident of _~~~-l.f~ _
(City) tab)
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and 1 ~esided at~' 'T~_~ . However 1 have changed my domiCile
(Street and Number)
to and am and. have been a bona fide resident of the State of Florida since __~-.s~__ day of
- 19.~V, and I reside at _ ~ ~ ~ fY0 - S~ J'f~ ~ ~ 'Q e f
. (Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORtDA
and this statement is to be taken as my declaration of citizenship, actual legal res+dence and domicile in the State of Flo~ida.
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(Insert here any pe?tinent fads, such as sale of property or busineu, or relinquishment of employment '
at forme~ domicile, removal of family to new domicile, purchase of home, e c.)
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! 20056~
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I FURTHER CERTIFY that 1 wil) oomply with all other rsquirements of a le~al resident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domicjle, and I intend to remain in FORT
?lERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
~y,vt~2 _./J J~~
(Name)
~.~'~`~~~u~~st+t~~~~~~. ~ . .
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'~3.~~~f,-,`~.i?~tt G~; (Address) -
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~4 ; s , i 'n ; ; s.~
• m• 6 ibsd before me this ~ da of `~~'y~~«- , 19~.
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CLERK CM~WT Notary Public .
By D.C. My Commission expires
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(T~ b~ ~x~c~1~d in dvp{icaf~ and eri~inal Af~d wifb Cl~k Grwif Carrf, ~ed duplicat~ wHh Taoc Ass~wer.1
~ ~i88 ~ 18i
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