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O~cluatio~ o/ Ootn1c11~ a~d Citis~nship
TO THE STATE MIU COt1NTY T/?X ASSESSOR,
51. ltK1E COUNTY, RORIOA: 2()~!Z4
This is mr decla~ation of Oomicile and Citiureship in the State of Florida that 1 am fifinq thi: day in aooordanoe and `
~n oonformiN with Chapter 222, Sactan 222.17, Flo~ida Stawros. ~
1 was formerly a le~al resident of ~L~u ~/L~/f'~ _
(City) -7 (State)
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and 1 resided at However 1 have chanyed my domicjle
(Street and Number)
to and am and have been a bona fide resident of the State of Florida sinae »1 ~iL,Y /I day of
- . 19~1Z, and 1 ~es'ide at ,T~f ~,~Q-.~
~ (Street snd Number)
FORT MERC~, SAINT LUC~ COUNTY, RORIDA
and this staternent is to be taken as my deciaration of citizenship, actval legal residence and domicile in the State of Florida.
(Insert here a~y pertinent facts, such as sale of propery or busineu, or relinquishment of employment
~
at former domicile, ~emoval of family to new domicile, purchase of home, etc.)
• fIlEO AMD REC4RQE~ i
S?.lUC1E CQ11N~ `
R06ER ~01TIUS (
REf:GRD ERiF EQ
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24 3324
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~ I RIRTHER CERTIFY that I will oomply with all other requirements of a leyal resident of this State.
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~ 1 FURTHER CERTI~1( that I have no intention b return to my former domicjle, and I intend to remain in . fORT
~ PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently.
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E (Name)
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~ Svrqm to ar+d subxribed before me this day of , 19~.
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~ ~y~~ ' " D.C. My Commiuion expires
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