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D~claratio~ ot Domicil• and Citis~nship
TO THE STATE AND COUNTY TAX ASSESSOR.
51, IUCIE COUNTY, FLQRIDA: .
This is my declarotion of Domicile and Citisenship in the State of Florida that 1 am filing this day in aooo~danos and
in conformity with ~hepter 222, Sectio~ 222.17, Florids Statutes.
1 was fotmerly a legal resident of UA10II Cit~? Peun. _
Kity) (Sta»)
and I resided at 17 K11bOr11 However 1 hsve chsngcd my domicGle
(Street and Number)
ro end am and have been a bo~e fide resident of the State of Florida since ~5th day of
~~1Lt~~ , 19 ~Q and 1 reside at ~ 517 S. 33rd St.
(Street and Number)
FORT M~CE, SAINT LtJCfE COUNTY, RORIDA -
and this stateme~t is to be taken as my declaration of citizenship, actual legal residente and domicile in the State of Flo~ida.
(Insert here any pertinent fads, such as sale of property or busineu, or relinquishment of employment
at forme~ domicile, removal of family to r?ew domicile, purchase of home, etc.)
(school chila)
Rocky I,ane Towmley - 2nd Grade 201562
i~ ~~E
RECORO ~tlER1~E1t0..r~..i:J~
- No~ 30 . 9 ~o ~M'11 -
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I FURTHER CERTIFY that I will aomply with all other requireme~ts of a leya) resident of thi: State.
I FURTHER CERTIFY that 1 have no intention to retum to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently. DOTthB SampeOri
(Name) •
~
(Addrsss)
Sworn to end wbsuibed before me this 30th day of November , 19 ?0
,~NiN.Hi.•/~k~/ -
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~ ~ ~ ~ Notary Public
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8y D.C. My Commiuion sxpires
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' and ori~inal fll~d whw Cl~elc Ciraih Cwel, and dvpNe~at~ wbh Tax A~~,?
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f . ~ ~ R 188 ~?~t 1666
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