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D~aluatb~+ 01 Domlcll~ a~d Citls~nshtp ,
YO THE STATE AND COUNTY TAX ~~SSESSOR. •
s~. wciE couNnr, ao~ia?: 2~3~i05
Thii is my declar~tion of Domicile a~d ~itizt~uhip i~ th~ St~t~ of Ho?id~ that I~m filirp thit day in aooorda~q and
in tonfo?mity with Chapter 222. Ssttion 222.17, Horid~ Statut~s.
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1 was formerly a Ipal ~esid~nt of h~e:~ms~
(Gity) (Stat~)
and 1 resided at . How~vK 1 haw char?q~d my domkil~
(Stnet and Numbe~)
b and am and have been a bone fide ~esidant of ths Stats of Floride si~oe day of
- . 19~, and I rosid~ at ~ ? D ,%y~ , ~ .
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(Stnst and Numb~r)
FORT MERCE, SAINT LUClE C4UNTY, lIORqA ~
and this statement is ro be taksn as my dsdaration of dti~enship, acteial le~al residena and domkile in ti~e State of Horida.
- (Inse?t he~e any pertinent facb, wd~ as sale of property or business, or relinquishment of employms~t
at former domidle, romoval af family to new domicile, purchsse of home, etc.)
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=`LLEUCIE COUNTY e~"• _
i10CER PO~T~S
CLEaK ~R
F
ED
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j~ 2~ 141 p~'11 .
203~605
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~ I FURTNER Cf~tTIFY that I will aomply with ali ofh~r r~quinm~nts of a Ipal rosid~nt of this State.
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1 FURTHER CERTIFY that.l have no intention to retum to my former domi~ile, and 1 intend to rerru~in in FORT
PIERCE, SAINT LUCIE COUNTIf, FLORIDA, permanently.
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~ .'~wqSwra '~ubsaibsd before me this day of 19
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y D.C. My Commission ~xpir~s
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