HomeMy WebLinkAbout1223 iGV~S 1:7.1. ' i
Dicluatla+ of Domiails a~d Citis~nshlp `
TO THE STATE ANO COUNTY TAX ASSESSOR,
51. 1t1C1E COUNTY, FlOR10A:
This is my detlatation of Oomicile a~d Citizenship in th~ State of Florida that 1 am filin~ thii day i~ aooord~no~ ~nd
~n oanfo~mity with Chapter 222, Settian 222.17, Florida Statutes.
1 was formerly s leyal residsnt of _ ~y~
(City) . (Stsh)
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and 1 resided at / - How~ver I Mve chanQsd my domiGle
(Street and Number) e
to and am and have been a bona fide ?esident of thb State of Florids sinae dey of
- , 19~, and I roside at ~ ~ ~~n~ G~=Dri
(Street and Number)
FORT ~IERCE, SAINT LtlCIE CQUNTY, RORIDA
and ihis statement is to be taken as my decla~ation of citizenship, ectual le~al residenoe and domicile in the State of Horida.
(Insert here any pertirtent facts, such ss sale of property or business, or relinquishme~t of employme~t
at former domicile, removal of family to new domicile, purchsse of honne, etc.)
203151
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WCIE COUM7TRrlA.
ROCER ro~TRA~
• CtERK CIitC1lIT "
RECORD YERtf IEO
,fu~ I I ~ 9 i2 ~M'11
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~ I FURTHEit CHtTIfY thst I will oomply with all other nquirerr~snts of a Ipal rasident of this Stat~.
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1 fURTHER CERTIFY that I have no intention to return to my former domic,ile, and I intand to remain in FORT
PIERCE, SAINT tUC1E COUNTY, FLORIDA, permanently.
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# '~.f ~ ~v ~ (f1ddrass) ~-7~ ~itl.t.l~ , _ .~~3f'C~t~
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~ ~Wbrwyb~ind svbscribsd before me this day of \ , 192~.
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~ ROOER ?ORRAS
~ ~ Nolary Public
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~ 8Y O.C. My f.ommi:sion expins
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~ lT~ b~ ~x~c~rt~d iw drplicM~ aw~ ~ioiwat fN~i wMi~ Clwk Graiif Ceuet, and d~licah wi1M Tax A~o~a
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~ ~~:o. 13 • • -
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