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D~cla~ation ot Oomicil• and Citis~nship
TO THE STATE ANO COUNTY TAX ASSESSOR. ~
51. tUC1E COUNTY, FIORI~A:
203i53 -
This ii my daclsration of Oomicile and Citis~~iF+ip in th~ State of Florid~ th~t 1 em filinq this d~y in aooord~nc* and
~n conformity with Chapter 222, Ssction 222,17, Florida Statute:.
1 was formerly a leqal ~esident of ~~R,C ~ r1~9~ y1.~.d~
(City) (Stah)
and 1 ~esided at .~.__~L(LT--~.~~,G!j~~~ A~ I~iowevsr 1 heve cfisnqsd my domidle
(Stnet and Numbe~)
to and am and have bee~ a bons fide resident of the State af florida sinoe /~t?d,Fflj,~•t~~L C dsy of
. 19~, and I roside at ~..~7~~ -S. !~L/ ~~~/~/g~P /~/P/ v.~
(Streat and Number)
FORT MERCE, SA1NT LUCIE COUNTY, I~OR~A
and this statement is to be taken as m declaration of citiZe~shi actual I !
Y p, syal residenu and domitile in the Stsro of Florida. ~
(I~sert here any pe~tinent facts, such a: sale of property or business, or relinqui:h~nt of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
^ f ~EO ANO REC R E
~ ~~.~OCER
PO
TRAS~
OIERK CIRCUIt C~I1RT
RECORO YER~FIEO~
Ja~ 1 t 10 i2 ~M'i!
i~iQ a.~~.Ju
' I RIRTHER CEltTIFY that I will oomply witfi all othar requirern~nf: of a Ispa1 rosident of thi~ St~h. .
;
' ! fURTHER CERTIFY that 1 have no intention to retum to my former domicjle, and 1 intend to remein in FORT
~ PIERCE, SAINT lUCIE COUNTY, FLORIDA, permanently.
;
me)
~a ~ls~~/
~ ~ ~~,f zr (Addres:)
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~ j:;~~J;~. ~~~;~~4t,subscribed before me this day of , lq~
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~ J1 ~ :ta . ' ~O~RT Notary Public
E "~Y ' ! ~.G. M
: ~ ' . y Commiuion expires
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. ~pUcat~ wMb Tax A~~.)
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