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~ecldration ot Domicil• and Citizenship `
TO THE STATE AND COUNTY TAX ASSESSOR,
51. IUCIE COUNTY, FlOR1~A:
This is my declarotion of Domicile and Citizenship in the Stats of Florida that I am filing this day in acco~dance and
~n conformiy with Chapter 222, Section 222.17, Floride Statutes.
1 was forme~l 1 I re i t - _~~i2~ ~l~v~_
y a ega s den o
~ " ~(City) (State)
and I resided at ..5~ However I have changed my domic.ile
j" (Street and Number)
to and am and have been a bona fide resident of the State of Florida since day of
.
`~~~L~ , 19~~/, and I reside at -
~ ~ - (Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Ho~ida. ~
(Insert he~e any pertinent fads, such as sale of p~operty or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
.
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I~c 1 3 y.~ /~'11
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~ 201853
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I FURTHER C'ERTIFY that 1 will oomply with all other requirements of a legal resident of this State.
I FURTHER CERTtFY that I have no intention to return to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
L~
(Name)
~ o r dt•i1/ ~~h-l-S~C~
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u:i~t;;;;;, ~ (Address)
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to~~~~cribed before me this o day of , 19~~+..f~
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_ • ' ' ,.~OURT / Notary Public
' ~y•'• is.~~~~~
By ' C ~ ~ ` .C. My ~ommission expirss
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(Te b~ ~x~arNd in duplicN~ and e~i~inal fil~d with Cleelc CircuN Cou~, aed dvplicab wifh Tax Asw~or.)
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