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O~Ciaratlon ot Domicil• a~d Citiz~~ship
TO THE STATE AND ~OUNTY TAX ASSESSOR.
Sl. LUCIE COUNTY, F~oR~oA: 201'791
Thia is my declaratior? of Domicile and Citize~ship i~ the State of Florlda thst I am fili~q this day in eoo~rdanas and
in oonformity with Chapter 222, Sectio~ 222,17, Florida Statutes.
1 was formerly a I_egal resider~t of r~"-~--t
(Ciy) (S~aro)
and 1 resided at ~2! ~L. l~. ~~~n! However I hsve chanyed my domicile
(St~set and Number) Yn
to and am and have been a bona fide resident of the State of Florida since ._le~~ dsy of
.
- . 19S~L, and I reside at ~Ql ~~~'~rL. ~ ~-"~"'L.t.~~
(Street a~d Number) ~a
FORT MERCE, SAINT LUCIE COUNTY, RORlDA _
and this statement is to be taken as my declarotion of citizenship, actual legal residence and domicile in the Stata of Horida.
(Insert here any pertinent fads, such as sale of p~operty or busineu, or relinquishment of employme~t
at fo~mer domicile, removal of family to new domicile, purchase of home, etc.)
~O'~r~~ c~, ~-h-~-.~oC. ...c~-~ ~ ~p e,h.a-~-~.
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CLERK C1R~~11~
RECOR011ERlftEO ~~~C ~ .
~c T II ~ AM 70 -
` 201`~91 .
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I RJRTHER GERTIFY that 1 will oomply with all other requlremen~ of a lepal restde~t of tfiis State.
1 FURTHER CERTtFY that I have no intention to retum to my former domicjle, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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Z; ~ before me this . day of . 19 .
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a~ i1RT Notary Public
By D.C. My Commiss'wn expiros
Re b~ ~x~arhd ie duplicat~ and o~i~inal fiMd will~ Cl~lc Ci~w~it Couet, aed d~lical~ w~Ib Tax A~erJ
: r~. ~s 6001(~C70 ~E~.1~.~
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