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~ O~alaratlon ot Domlail~ a~d Clti=MShip ~
TO 1HE STATE ANC COUNTY TAX ASSESSOR. 2U~~2
Sl. tUCiE COUNTY, FLORIDA:
Thi: ii my declaration of Domicil~ a~d ~itinnship in th~ Stat~ of Flaida that 1 am filinq thi: day in ~ooo?d~na and
~n conformiryr with Chapter 222. Section 222.17. Florids Statut~s.
I was fo~merty a la4al residant of ~+~1~
(City) (Sta»)
end I resided at Howevar 1 have chanqed my domidle
(Stnef and Numbe~)
/
to and am and have been a bona fids reside~t of the Stab of florida sinoe day of
, 1911L_, and 1?eside at ~;QU 9~-~o-~'
(Street and Number)
FORT r1ERCE, SAINT LUCIE COUNTY, I~ORt~A
and this statement is to be taken as my daclaratwn of citizenship, actual legal residenoe a~ domitile in fha Staro of Horida.
(Insert here any peninent fads, such as sale of property or business, or ~elinquishment of employment
at fo~mer domicile, removal of family ro new domicile, purchase of home, etc.)
YlFrx~~'/
FILE~ ANO RECOROE
, iT. LUCIE COUNTY.f~
. ROCER POITRAf
CLERK CIRCUIT COIMT
~ RECORO YERIFtEp~
8 10 29 AM't I
~ 2C3442
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~ I RIRTHER CERTIFY thst I wil! aomply with all other requiremsnls of a le~al resident of this State.
~ I FURTHER CERTIFY tfiat I have no intention to retum to my former domitile, and I intend to remain in FORT
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PlERCE, SAINT IUCIE COUNTY, FLORIDA, perma~ently.
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(Name)
~ ,C it/.~P~c~ f'/. ~~.~i
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~ 'fi~iiar~i;t~cgh~i."su"~icribad before me this ~ day of ~ , 19~
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~ 't s.431 e ~ G• ~t ~
~ •'Y,.''~'.''s `.c'<~ "
~ ~ COtlRT Notary Public
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~ By D.C. My Gommiuion expires
••re:~ae•
~ R~ b~ ~x~cuhd 1n duplical~ snd ai~inal fll~d wilb CiKlc Grcuk Cou~t, and dupNsal~a wNh T~x A~e~a
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~ ~ „ 80~189 ~~~E1622 =
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