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O~lu~tlal 01 DOm~i~~ a111~ CItlsMfihlp
TO THE STATE AND COIJNTY TAX ASSESSOR.
51. lt1CIE COUNTY. FlOR10A:
Thit is my dscl~re~io~ of Oomitil~ •nd CitizMthip in th~ St~t~ of Florid~ that 1 arn filinq this day i~ ~coo~dano~ and
in tonformity with Chapter 222. Settion 24Z.17, Florida Statut~s.
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I was forme~ly a IeQal resident o _
(City) (Stat~)
and 1 resided at - Hovwvar t hav~ tharp~c! my domicjle
(Strest and Number) y Q ~
to and am and have been a bona fide rosident of tht Stsro of Florida sinoe day of
6 ..~Q . ,
- . 19~ and 1 roside at
(Stnet Numb~r)
FORT M~CE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my dedaration of citizenship, actual 1e9s1 residenoa and domicil~ in the Stat~ of Florida.
(Insert here any pertinent fac~a, such as sale of property or business, or relinquishrnent of ~mployment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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~ I FURTHER ~ERTIFY that 1 wil) comply with all other roqui~ts ot a leyal resident of thk Stats.
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g I FURTHER CERTIfY thst I have no intention to return to my former domitile, and 1 inter~d to remain in FORT ~
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ,
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-~~''.5worn to and"subscribed before me thi: ~a dey of 19%,L.
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~ ROGER rO1TRAS
~ CIRCUR Notary PuWk
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By o.c. My co~,~,~u~«+ .x~~~
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~ ae 1» .x.a~.a M aup~cs~..~d ..i~w.~ f~ ,~Mi~ a..k cM~i1 c«M+, .pa a,iN~ Tax A......ra
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