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Declaration ot Don~i~il• and Cltis~nship
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, FIORIDA:
This is my decla~stion of Domicile end Citizenship in ths State of Florida that 1 am fili~ this day in aaordsnce and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
I was forme~ly a legal ~esident of ~ f°~ ~'r e~"`r ~ r~
~
(C~ry) (State)
and I ~esided at ~0 4t - 3~ ~ However 1 have changed my domitile
(Street and Numbe~)
to and am and have been a bona fide ~esidcnt of the State of Florida si~ce ~L day of
~"t. • ~~X
_ - - - _ - 19~~_, and I reside at t~' ` G.~C<-'-p •
c~o
O~~ •
FORT W~CE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citize~ship, actual legal residence and domicile in the State of Horida.
(Insert here any pertinent fads, such as sale of property or busineu, or relinquishment of employment
at former domicile, removat of family to new domicile, purchase of home, atc.}
Establf~ins raaid~ac~
ST~LUCIE COUMTY F1~
ROCER FOI~RAS
~~fRK CIRCUIt COUItT
RECORD YER?FIEtf
OEC 23 9 v4 AM'10
i 202435
~
~ I RIRTHER CHtTIFY that I will oomply with all other requirements of a lefla) resident of tfiis State.
f FURTHER CERTIFY that I have na intention to return to my former domi~ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
~,,F ol ' ~Y a~~-z~ ~Z~r-
(Name)
~ !'red H. Bnd~l~an
~ .
~
~ (Address)
~
~ 1~rn ~'o: ,wbscribed before me this ~ day of ~a~~r , 19 T0,
~ : ~ ' ~ ,r ~
_ . ~ ;
y~~ ~ CG % :
~t~~~; ~ ~ .
_ ` ; I .
. 3 ~pU~T No1ary Public
~ JS. ,Tl~ ,
~ gy' N ~ 1 ~.C. My Commission expires
. ~ ~ G ~
Ro b~ ~x~cvhd in dupiicat~ and ori~na! fil~d wi~h Cl~rk Grwit Cor+r~, and duplicat~ witb Tax Ass~swr.I
, a BG~K ~~7~7 Pt,Lf
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; , ~ ~ ~
~ ~ ~ ~
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