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D~ala~atio~ o! Oomiail~ and Clt~~nahlp
TO THE STATE AND COUNTY TAX I?SSESSOR,
51. lUC1E ~OUNTY. FlOR1~A: .
Thii is my declaration of Oomicile and Citit~nship in th~ St~~o of Flo?id~ Mat 1 am filinq this day i~ aoo~dana ~nd
~n conformity with Chapte~ 422, Saction ~~~.17, Florida St~tutes.
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1 w~s formerly a Ipal resident of ~ . _
(Giry) (Stat~)
and 1 rosided at ~6L~7~_~ ~ However 1 have chan~sd my domitile ~
(Strset and Number) - '
b and am end have been a bona fide resident of the State of Florida since ~7 day of
, 19~ snd I roside at ~~a e-6lL~:+~de~J ,~e!~ -
(Stre~t and Number)
'fORT M~CE, SAINT LUCIE COUNTY, RORIOA
and this statement is to be taken as my decla~ation of citizenship, actual legal residence and domicile in the State of Florida.
(Inse~t here a~y pertinent facts, such as sale of properiy or business, ar relinquiahment of employment
at former domicile, removal of famiiy to new cbrt~icile, purdtase of home, ett.)
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fttEO 4N0 RECORQf!
=T. ~t1~lE COtlMT~ Fu .
ROCER POITItAS ~
CLERK CIRCUIT COYItT
RECOAD YERIFIEO.,~.~~
Jur 15 10 24 AN'T 1
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~ I RIRTHER ~ERTIFY that 1 wil! aomply with all other r~quirements of s le~al residant of this State.
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~ 1 FURTH6R CERTIFY that 1 have no intention to retum to my former domicjle, and I intend to remain in FORT
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~ PIERCEt ~,i,~1~.COUNTY, FLORIDA, permanently.
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~ '~.td ~}~d wbsuibsd before me this day of 19.~
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~ GRCUIT COtJRT Notary Publk
~ B `~'`''4'e" ~ D.C. My ~ommiuion ~xpires
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Re b~ ~x~arl~d in dvplieat~ ~nd e~i0inal fll~d with Clalc Cira~if Couel, ~nd duplk~aN whb Tax A~ra
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