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Declaration o! Domicile and Citisenship ~
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TO THE STATE ANO ~OUNTY TAX ASSESSOR, 1
Sl. LUCIE COUNTY, FLORIDA:
This is my declaration of Oomicile and Citizenship in the State ef Florida that I ar*? filing this day in aocordante and
~n co~formity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of -~~laIId_ _
_ (Ciy) (State)
end I resided at ___Aahland. , However I have changed my domiti~e
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ____~p~~_- day of
- . 19 and I reside at 1404 Sottl~h lOtrh 3tleet
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORIOA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Inse~t here any peninent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
8atablishiag r~aidency
I an a~ty-nine aad dah to have a iis6in~ liaease
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iT. ~lICIE C011MTr~
ROOER POITItAt
C~ERK CtRCWT COYRT
RECORO YENIFIEO.~~~
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~ - 20062r3
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1 FURTHER CERTIFY that 1 will oomply with all other requirements of a leyal resident of this State.
1 fURTHER CERTIFY that I have no intention to return to my former domicjte, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. _
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" (Name) y~{hei' Batker
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~~3g~~ed before me this ~b day of N~~~ , 19 TO
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~~1i1~COURT Notary Public
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- ~ By D.C. My Commission expires
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Ro b~ ~x~cvt~d in duplfut~ •ed ori~inal fil~d whh Cl~rlc Grcuk Cou~, and dupllcat~ with Tan Ass~o~.)
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