HomeMy WebLinkAbout0963 2(~2:)f~t~
D~laration ot Do~nl~il• and Citis~nshlp
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl . IUGfE 'COUNTY, FLORIOA:
This ~s my declaration of Domicile snd Citizenship in ths St~te of Florid~ that I am filinq this day in aooord~noe and
conformity with Chapte~ 222, Section ~22.17, Florida Statutes.
1 was forme~ly a legal resident of
(Ciy) (Stah)
and 1 resided at ~~,,GI/~ -.L1L~~ ~ However I have chanyad my domic~le
(Street and Numbe~)
to and am a~d hsve been a bona fide reside+~t of the Stats of Florida since i
O d G~ -3 v day of
_ . , 19~, and I reside at y~Z ~~R O-r0 l~V'~
(Straet s~d Number)
FORT r1ERCE, SAINT ttlClE COUNTY, RORiDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Horida.
(Insert here any pe~tinent facts, such as sale of property or business, or relinquishment of employme~t
at former domicile, removal of family to ~ew domicile, purchsse of home, etc.)
. 1
~ /
. S~
202Jf 9
f LED ANO RECQ,RQ~~
`{lCIE COW11 T Fu4
RdCER PQITRAi ~
CtERK CtRCYlT QOYRT
RECOIID YEItIf1ED
.~N ~ ~ 12 ~'j ~
E .
~
~
€
~
~
1 FURTHER CERTIFY that ! will oomply with al) other roquiremenn of s leyal r~ident of this State.
~ I FURTHER CERTIFY that I have no intention to return to my former domicjle, and I intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. CQ I'~ /rl. ~yen~ P I` 7~
~
~ ~1~-
~ (Name)
~
~
~
~
(Address)
~ ~ ~
~ Sworn to and suburibed before me this day of , 19~~.
- :t:~ttr .1~~~~`f' "
~
~ ' • ` Notary Public
ti" ~ .
By D.C. My Commission expi~es
~ ~r ~ ~ . ~ - : ~y r
~ ~J~ `~,t ; y ~
r ' ~1 Pa ~ ~ .
~
' ~ 0~ '~~~t ~ .
. .i``,~14iplicar..nd oei~inal fii~d wilb a«Ic urwit co~~, ,nd d~pliat. wilh Tax ~?.....ora
~ u~t~~~~:?+~ -
~ „ _ Bo%K 1~9 Pasf 96Q .
~ _ - _ ,.y
r~ _
x~ . _ : _