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~claration ot Domicil• ahd Citis~nship ~
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TO THE STATE AND COUNTY TAX ASSESSOR~ ~
Sl. tUC1E COUNTY, FLORIOA: j
203010
This is my declaration of Oomicile and Citi=enship in th~ Stau of Florida th~t 1 am filinq this day in ~ooo~dana a~d
~n tonFo~mity with Chapte? 222, Sattio~ 22Z,17, Florids Statutes.
I wes fo~me~ly a legal reside~t of _
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(City) (Staro)
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end 1 resided at _ However 1 have cfia~~ed my domitfle
(Straet and Number)
to and am and haye been a bona fida resident of the State of florids since / ` ~ dsy of
,
_ . 19--, and 1 ~eside at r,~
~T~ ~ • ~ (
(Street and Number)
FORT ~IERCE~ SAINT tUCIE COUNTY, RORIDA
and this statement is to be taken as my decla~ation of citizenship, actual Inyal residence and domicile in the State of Horida. ~
(Insert here any perfi~ent facts, such as sale of property or busineu, or reiinquishment of employment
at former domicite, removal of family to new domicile, curchase of home, etcJ !
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f~LEO ANO RECOROE~
~IE COUMtI? fu
c~ER~c c
Rcun~
RE~O YERlfIEp'~~'~
'+I~M s Z OS PM'T~
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~ I FURTHER CERTIFY that 1 will comply with all other requiremenfs of a layal resident of this State.
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~ I FURTHER CERTIFY that 1 have no i~tention to return to my former domicjle, and I intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ h/.9~P/ej/ y, (Name) S /4 f,Ei~
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~ ''F:•~`.c~~tq~~qc~ subscribed before me this da of 191~.
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~ ' COtlRT Notary Public
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~ ,8y ~ D.C. My ~ommission expires
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~ Re b~ ~x~aM~d fn dvplicsh ~nd eri~inal Al~d w1ti~ p~lc Gra~it CouN, and dupl~cN~ with Tax AtMS~or.)
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~ ~ 600K ~89 PAGE~O16 ~
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