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O~cla~atio~ ot Oomicfi• and Citis~nship
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TO THE STATE AND COUNTY TAX ASSESSOR.
Sl. llK1E COUNTY, FLORIDA: ~O~ns3
This is my declaration of Oomicile snd Citize~ihip in the State of Florid~ th~t I•m filinq thi: day in accorda~oe snd
~n confo.mity with Chapte~ 222. Sectio~ 2?2.17. Florids Statut~s. .
1 was formerly a legal resident of sx- ' -
(tity) sh)
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~nd 1 ~esided at ~1~~ ~ However 1 have thsn9ed my domicjle
treet and Number)
to a~d am and have been a bona fide ~esident of the Staro of Florida sinoe ` ___,L day of
_ - , 19._,,~~ and I reside at ~ - -
O~~ p~. (Str~ snd Number)
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FORT MERCE, SAINT LUCIE COUNTY, fLORt~A
and this statement is to be taken as my declaration of citizenship, actusl legel residence and domicile in the State of Florida.
(Insert here any peninent facts, such as sale of property or business, or relinquishme~t of employment
at former domicile, ~emoval of family to new domicile, purchase of home, etc.)
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JLEp AND RECOROf~
ST. ~l16tE COUfIT1f flA,
ROCEN FOITIU= '
CtERlI CUIC~ C011RT.
RECQRO YER~FIEB .
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~ 1 FURTHER CERTIFY that 1 will oomply witfi all othe~ rsquirement: of a leyal rssident of this State.
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1 FURTHER CERTIFY that I have no intention to return to my former domicjle, and I intend to remain in fORT
E
~ PiERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ (Name) ~~7 i f ~
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~ (Acfdress)
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~ ~.y~v~D1 ~ia ,~rid~;yrbscribed before me this ~ day of ~ , 19~
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~ , s t~ 1~:b~YRT Notary Public
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~ By ' D.C. My Commiuion expi~es
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