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O~claratian of Qomiall~ a~d Citis~~ship
TO THE STATE AN~ COUNTY TAX I?SSESSOR,
51. UlCIE ~OUNTY, FLORIOA: •
This is my declarstion of Oomicils and Citiz~nship in tM Stau of Florid~ th~t 1 am filin~ this day in aooordana and
~n confwmity wlth Chapter Z2Z. Section 222.17, Flo?ida Statutes.
1 was formerly a legal ~eiident of 77v O Se~v o,
(City) (Stat~)
and I resided at _ ~ 7 d - . However I have charpsd my domidle
(St~eet and Number)
to and am and have been b bons fids resident of the Stste of Florida since M~ 'ZO,s u r+~-~--
- - . 19..Z and I reside at ~ ~ ~ ~ `~~N SoVi~VA Ti~,!',p~! t~ _ ~
(5treet and Number) ,
FORT M~CE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my decls~ation of citizenship, aetual legal residence a~d domicile in the Staro of Horida..
- .
(Insert here any pertinent fatts, such as sale of property or business, or relinquishment of emptoyment
at formar domicila, removal of family to new domicile, purchase of home, etcJ
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' 2031`75 ~
F0.E0 AMQ ~
St. 1lCIE.C
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CtER~ C~~~
ItEC4~0 VER~ftEO
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1 FURTHER GHtTIFY that I will comply wifh all other requiremenh of s(eQal resident of this State.
I FURTHER CERTIFY that I have no intention to retum to my forme~ domicjle, and I intend to remain in FORT
PIERCE, SAINT LUCIE CQUNTY, FLORIDA, permanently.
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:~~vn' I before me this ~ day of ~ , 19~1_.
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ROGEk' 1~O~AS
C K CIRCUfT COURT Notary Public
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gy D.C. My Gommission expires
Re b. .x.nr~.d iw d~plic.+. and e.isinal fil~d ,whl~ au~c u.wN cowt, .nd d~pltc.+. wiM~ T.x A.....ora
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R~ 189 p;~f 1251
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