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Olai~tat~OA Of OOAN~11~ aAfl CltiiNlil~ip
TO TME STATE ANO COUNTY TAX ASSESSOR, ~ 2(~~1~"7
st . wcrE cout~nr, aoRia?:
This is my d~cla~~tion of Oornicil~ and Citi~sAip in tM St~N of Horida Hwt 1 an+ fili~q tP~is day i~ ~o~oordano~ and
~n conformity with Chapt~ ZZ2. S~ttion 224.17. Florida Stafuhs. -
I was fo~lr a Ipal nsid~nt of ~~~S~O L V/!~ r"''~7
trity) l'St~tr)
and 1 r~sid~d at ~v ~olcW10 f~ S~ Howww i hav~ d?~rq~d my domitil~
~ Rt~'~N and Nu~r+bK)
b ar+d am .~d haw b.a~ a bo~+, fid~ nsidam of th~ Stat~ of Florida sinoe ~~L b day of
~4 7~ ..~,a i~.~ ~0 3 . yd r~ ST F7- D i~ RC ~
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~ott ~+e~c~. s~ w~aE couMnr, aoRiow ~
snd this stat~nent is to be take~ as my deduation of dtira~ship. ~ciuai lpal r~idar~oe a~d do~nicil~ i~ tM StaN of Haid~.
(Insert hera any pertinant fads, wch as sale of propKty or business. ot relinquishment of ~mploymsnt
At former dotnitile. roRwvai of familr b new domitik. Purchas~ of Iwme, ettJ
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' ~ ~ ~ 20304'7
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~ I FURT1iHt C6tTIFY thst I will oanply with all otF~ roquiram~tts of a lpai ro:ident of tfiis Sta~e.
I fURTNER CERTIFY that i h~ve ~o iMe~tion to retum to my former domic~le, and 1 iMend to remain in FORT .
PIERCE, SAINT UKIF COUNTY, FLORIDA, psrmanenHy.
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(Name) s l~ e~ i ~ .
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{Address)
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" ~;,~t:asu~irii.~+~ ~ :
.,,;~}i~o:~ ~ befort me this da~r of 19~
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_ Notary Publk
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5~? C.C. My Gorrwniuion ~xpiru
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