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O~claratio~ ot Domicile and~ Citise~shlp ~
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TO THE STATE AND COUNTY TAX ASSESSOR, •
F
51. IUCIE ~OUNTY, F~oRioA: .
This is my declaration of Oomicile and Citizenship in the S~ate of Florida that I am filing this day in aocordance and
in conformity with Chapter 222, Section 222.17, Florids Statutes.
. Pa ~ ~ _ _
I was formerly a legal ~esident of _~~Qi~-__-
~ (City) (State)
and 1 resided at _-'~!-QS-/ ' ~ However 1 have changed my domitile
(Street and Number)
ro and am a~d have been a bona fide resident of the State of Florida since -___L_~~'__--- _ day of
~ v ~S dn
.__~J:_f/~Ge~ e r . 19~aand I rtsida et ~
(Street and Number)
FORT M~CE, SAINT lUC1E COUNTY, ROR10A
and this stateme~t is b be taken as my decla~ation of citizenship, actual legal residence and domicile in the State of Flo~ida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, r al of f mily to new domicile, purchase of home, etc.)
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1 FURTHER ~HtTIFY that I will oomply with a!I other requiremenri of a leyal resident of this State.
1 fURTHER CERTIFY that I have no intention to retum to my former domiti~e, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTIf, FLORI~A, permanently. '
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(Name) -
D/ ~ -
(Address)
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Sworn ro ibsd~afore me this day of , 19~.
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r ~ • s Notary Public
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ey ' ~ - ~.C. My ~ommission expires
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R~ w~x~uA~i ~~ital~ and orioieal Al~d w~ CI«k Ci~M Coue1. ~nd dupllut~ wiN~ Tsx As~.I
g~1gg ~16'2U
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