HomeMy WebLinkAbout0768 O~cluatio~ ot Domicil~ and Citi=~nship
TO T!~ STATE /W~ COUNTY TAX /?SSESSOR. 2~ 28~
s~ ~uaE co~,~r, aoR~o~? .
Th~s ~s m~r decla~atwn of Oom~ule ~nd Citizenship in the Stare of Florida that 1 am fil~nq this day in accordance and
~n conformit~? w~M Chapter 222. Se~ttion 2Z2.17, Florida Statutes.
1 was formerly a legal res;dent of , - - , •
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snd 1 residad at _3 Nowever 1 have chan~ed my domicile
(Street a~d Number)
ta arxJ am and have been a bona fide resident of the State of Florida since __-____~~J~ day of
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~~Z~""~~--- . 19~
~ and 1 roside at 'r ~ ' ~ • ~
(Street and Number)
FORT ~lCE, SAWT Lt1C1E COUNTY, RORN~A
and th~s statement is to be taken as my declaration of citizenship, actual legal residenoe and domicile in the Staro of Horida.
i~~t here any pertinent facts, such as sale of prope~ty or business, or ~elinquishment of employment ~
at forrr~ domicile, removal of family to new domicile, pu~chsse of home, etc.) ~
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FIlEO A110 RECORpEO
s1: lllClE COUN~Y fL~
ROCER POITRAS
CLER~ CIRCUIT COUAT
RECORO VERIFIEQ
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~ 1 R1RTFlER ~HtTIFY that 1 will compty with all ott~er requirements of a legal reaident of this State.
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a 1 FURTHER CERTIFY that 1 have no intention to retum to my former domicile, and I intend to remain in FORT
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P?ERCE, SAINT LlK1E COllN7Y, FLORIDA, permanently.
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~ ~ (Name) u ,
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a .~,~,~r~prn tc and wbxr~bed before me this day of , 19~
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~ ~ .~,".~,Q~ Notary Public
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~ gl~' ~ O.C. My Commiuion expires
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~ Rs w~.~.r : r~.d a..k ~ a~aiuN with Tax
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~ b gcJ~l$9 ~,c~ 7'66
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