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D~cla~ation o1 Domlcfl~ a~d Cltis~?nship
TO THE STATE AND C~OUNTY TAX ASSESSCIR. ~U~ ~
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51. U1CIE COUNTY, FtORIDA:
Thi• is my declar~tion of Domicile and Citiz~nship in th~ Stat~ Qf Florid~ that 1 am filinp thii d~y in accord~nu •nd
~n conformity with Chapter 22?, Section 222.17. Florida Statutts.
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1 was forme~ly e le~al ~~ident of ~~~-~~'~'L41.~•'?'C t/ -
(City) (Stat~) .
C ~~z~ ~v
and 1 resided at u~ . Howevar 1 have chanqsd my domic3le
(Streef and Numbe~)
b and am and have bea~ a bona fide resident of. the State of Florida sinoe ~ day of
y .
L , 19~C , and I m~ide at ~t"~
(5treet snd Number)
FORT NERCE, SAlNT LUCIE COUNTY, fLOR10A
and this statement is to be taken as my declaration of citizenship, actual leyal residenoe and domicile in the State of Horida.
(Inse~t here any pertinent facts, such as sale of property or business, or relinquishme~t of employmant
at former domicils, removal of family to ~ew domidle, purchase of home, etc.)
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20~84
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I FURTHER CEftTlFY that I witl comply with sll other requirem~nts of a lepal resident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domitile, and I intend fo remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORI~A, permanently. ^
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,,:.~:u~~urr,; ~ ~ F-- < < (Name) ~ ,~E M~ N K
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;=Sw~orn !p•~~iubscribed before me this ~ day of 19~
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~ dRC COURT Notary Public
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~ y D.C. My Commiuion expires
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Qo b~ ~x~evl~d in duplisah aed ori0iwrl fiwd whh Cl~lc Cin~it Ceuh, aad dvpliaN wMw Tax A~ra
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