HomeMy WebLinkAbout0977 Deciaratio~ ot Domicil• and Cltisenship
TO THE STATE AND COUNTY TAX ASSESSOR, • '
Sl. WCIE ~OUNTY, FIORiDA:
This is my declaratio~ of Oomicile and Citizenship in the State of Florida that 1 am filing this day in acoordante and
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~n conformity with -Chapte~ 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of _ _ ___Cbica~o _ ~ _ _ _ I11 _ _ -
(City) (State)
and 1 resided at ----~28 w S3.Plaoe ~ . However 1 havechangad mydomitile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since Q~d__.___~ day of
19-70, and I reside at _____1'!3 Ialceharat Port 4t. I.neie
(Street and Number) ~
fORT lNERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actval legal residence and domicile in the State of Horida.
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(Insert here any.peninent fads, such as sale of properry or business, or reli~quishment of employment
at former domicile, removal of family to ~ew domicile, purchase of .home, etc.) ,
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Eatsblishin~ r~aidence =~1~ O,~p R 4
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~ 1 FURTHER t'HtTiFY that 1 will comply with all other raqulremsnri of a(eflal 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 IUCIE COUNTY, FIORIDA, permanently.
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i~ly ~V~ ~~J.~ F" -t' ~ P
ts •ti : (Name)
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~O ~ R : ~ A~ene Or~ebin
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, :~j~~ fr.'~~; (101df~f6S5~ . ~
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-4 FL C }
5wb'r~?"fo~and subscribed .before me this lT~b day of November ~ 19 TO ~
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ROGER POITRAS
CIRCUR ~QURT Notary Public
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By ~p D.C. My Commission expires
(To b~ ~acut~d in dupliut~ aed ori~inal Al~d wiTh Cbelc Cirwit Court, and duplicat~ wHh Tax At~or.)
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