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Decla~ation ot Domicil• and Citizenship
2U1405 ~
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY, FIORIDA:
This is my declaration of Oomicile and Citizenship in the Stata of florida that I am filing this day in accordance a~d
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was forme~ly a legal resident of _ ~
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(Ciy) (State)
and 1 resided at ~~e~ N~~~-- V However I have changed my domicjle
(Street and Number) _ ~
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to and am and have been a bona fide reside~t of the State of Florida since _~_~P _ day of
~1?~2-r _ , 19~ and I reside at ~ 1 ~ ' ~Q-~ aM"~S ~~V e- ~utl~
c~'C 'RQ2~_ (Stre~t and umber)
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA ~
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in ihe State of Florida.
(Insert he~e any pertine~t facis, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.) ~
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1 FURTHER CERTIFY that I will oomply with all othe~ requirementa of a lega) resident of this State.
_1 FURTHER CERTIFY that I have no intention to retu~n to my former domitile, and. I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~Sl`~4~jpt`~°~~d before me this ~ day of ~~~:'-'G~~~L , 19,,~
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By ' ~ ~.C. My Commission expires
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(To b~ ~x~cul~d 1n duplicst~ and ai~i~al fibd wkh G~k qrwM Couif, and duplic~h with Tax A~ws~or.)
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