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Declaratlon of Domi~il• and Citiz~nship ~
t0 THE STATE AND COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY, FLORIDA:
This is my decla~ation of Domicile and Citizenship in the Stats of Florida that 1 am filing this day in acowdancs and -
~n co~formity with Chapte~ 222, 5ectio~ 222.17, Florida Statutes.
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I was famerly a legal resident of
(Ciy) (State)
and I resided at ~ _ However I have changed my domiG~e
- (Strset and Numbe~) ~ .
to and am and have been a bona fide resident of the State of Florida sinca ~T day of
~
. 19 ~ , and I reside at ~ -
z
(Sheet and Numbef)
FORT WERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of cititenship, adual legal residence and domicile in the State of Florida.
(Inse~t here any peninent facts, such as sale of p~operty or busi~?cu, or relinquishment of employment
at former domicife, removal of family to new domicile, purchase of home, etc.) ~
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1 FURTHER CERTIFY that I will comply with all other raquiremenK of a Is~aal resident of this Stats.
I FURTHER CERTIFY that I have ~o intention to retum to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT IUCIE COUNTY, FLORIDA, per~nanently.
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I~''9wotn'b and subscribed before me this ~ ~ day of , 19
~OITRAS
CIRCWT Notary Public
d~t%~~'.l~C~ -
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9y D.C. My Gommiuion expi~es
tTe 6~ ~x~cui~d in duplicaN and ori~inal Ni~d wilb Cl~eic Cir~wit Coue1, and dupli~aN with Tax At~a~ora
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