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D~alatatlon o! Oomlall~ a~d Cittzt~shlp
TO THE STATE ANO ~OUNTY TAX ASSESSOR,
Sl. lUC1E ~OUNTY. FIORIDA:
this is my declaration of Domicil• and~Citiunship in th~ Stats of Florid~ th~t 1~m filin9 thit day in ~ooord~no~ ~nd ~
in conformity with Chspter 22~, Section 222.17, Flo~ida Ststutts. ~
. ~
I wes forme~ly a leyel ~esid~nt of
(City) (St~t~~
and I resided et _~Q.~:d~ Ci~ 01 . Fbwever 1 have cha~qsd my domk~ile
(Str~f and Numbe~)
to and am and have been a bona fide resident of the Stste of Florida sinoe ~ day of
. , 19_1L1, and 1 reaide at ~ 9~ O ~ q
(Street and Number)
FORT r1ERCE, SAINT LUCIE COUNTY, RORiDA
end this statement is to be taken as my declaration of citi=e~ship, actual legel residenos and domidle in the Staro of Horlda.
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(Insert here any pe?tinent facts, such as sale of propery or_business, or relinquishment of employme~t
st former domicile, removal of family to new domicile, purchase of home, etc.)
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i1LE01U1' RE~
sT lrCiE COWITY
ItO~ER ?OITItAt
~ CIFRK ClRCtlIT C91MT
RECOIlO YERIFIEQ.~.~..~
f ,~MI 13 2 22 PM'TI -
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~ 1 FURTHER CERTIFY that I will comply with all other requirements of a lepal resldent of thk State.
I FURTHER CERTIFY that 1 have no intention to return to my former domi~jle, and I intersd to remain in FORT
PIERCE, SAINT lUC1E COUNTY, fLORIDA, permanently.
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z~~~';. , (Name)
` ~i i'a
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~ ~sr~:.~::. ` " G°?ddress)
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..:.rSi~n to and subscribed before me this ~ day o , 19 .
ROGER rO1TRAS ~
CIRCUR COURT . Notary Public
~ BY ~'``'G~ D.C. My Commi:sion sxpires
(Te b~ ~x~arhd in duplicah ~nd oripinal Al~d wilb ClNlc Gnari? Co~e~, ~nd dvp~ wiN~ Tax AaN~a
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