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O~al~~ation ot QomlWl~ a~a! P•itlsw~shlp
TO TNE ST/1TE M1D COUNTY TI1X ASSESSOR, ,?,Q~~~
51. tUC1E COU~ITY, FLORIDA:
Thi: is my decluatio~ of Oomicits ~~d Citinnihip in th~ Stat~ of Horida thae 1~m flli~+q thit d~y in aooo~d~na Md
~n tor~formity with Ch~pter 222, S~ction Z22.17, Florid~ St~tutK.
1 was fo~ms~ly s Ip~l ~esid~nt of . I~ 0 4 ~l lI E R N ~ aI N E~ ~ n K\~
(City) (St~h)
a~d ~ ~es~ded at __1~~ IY BAN S~,_ Howevsr 1 haw chanQsd my domiCi~~
_ (Stn~t and Number)
~o and am and have baen a bona fide res'ident of the Stat~ of Florid~ si~oe ~_1 ~ clsy of
G~Te~_~l~ ~ 330 3 M6Noo ~.~.t I~AN~
- . 19~ , and I rosid~ at
(Sh~t and Numbsr)
l~ORT M~CE, SAINT LtK1E COUNTY, RORIDA .
and this statement is to be taken as my declaration of citizenship, actual Isyal residenos and domicile in ths State of Horida. .
(Insert here a~y pertinent facts, such a: sat~~f' property or businssa, or relinquishment of employment
at former domicile, removal of family ro ~ew domicile, purchase of homa, etc.)
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° I FURTHER CERTiFY that I will oomply with elt other requinments of a Is~al resident of this State.
~ I FURTHER CERTIFY that I have no intention to retum to my former domicjle, and I intend to remain in FOI~T
~ PIERCE, SAINT LUCIE COUWTIf. FLORIDA, permanently.
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~ (Name) lfatthN? C'bt~pesla
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~ •_~'~;to and wbsaibed before me this ~5- dsy of 19~
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: , : ~WIT CWJRT Notary Public
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~ Dyy 3 D.C. My ~ommiuion expires
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~o~ 1g9 P~ 88~ -
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