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D~aiaratio~ ot Oomlail• snd Cltl:~nship
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. tUC1E COUNTY, FIORiDA: '~~j~i~
This is my decla~ation of Domicile and ~iti=enth~p i~ the State of Florida that I am filinq this day in ~coord~nc~ and
conformity with Chapter 22?, Settion 222.17, Ftorid~ Statutas.
I wss forme~ly a leqal resident of - - - <
< ~ ~NT ) _ _ ~ 1 C . -
(City) (Stah) .
and I ~esided at 33 7 5 ~ ~ C~ 16 A'N !`N ~ #Z 8~--, ~weve? 1 hsve chan~ed my domic,ile
(Strest and Numbe~)
to and em and have been a bona fide resident of the Stats of Florida since day of
- v~ 19.LS~, and 1 reside at ~ S~'RID f~} - ~0+~ S7- LLt.~ E
(Street and Numher)
FORT M~CE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declarotion of citizenship, actual legal residence and domicile in the Staro of Horida.
(Insert here any pertinent fads, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
~ _
tT.lUC1f COUNTY flA.
ROCEA POITRA= ~
ClER1I CtRCUIT CQUR C~
RECORO VERIF1Ep.,~`~ v
. ~AM ~6 ~Z 24 ~'7 ~
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~ I FURTHER CERTIFY that I will oomply with al) other requirem~nts of a la~a) resident of this Stats. ,
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~ I FURTHER CERTIFY that 1 have no intention to ~etum to my former domitile, and I intend to remain in FORT
~ PIERCE, SAlNT LUCIE COUNTY, FLORIDA, permanently.
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~ a~•:~. , ~ `~i~scrH~sd before me this ~ ~ day of «Z , 19~
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~ ~ Rtl~t~'~rt~?s
a :
~ CIRCNR COURT Notary Public
~ B D.C. M Gommission ~x ir~
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~ R~ b~ ~x~arNr ie duplkaN and ori~inal Al~d wM~i Cl~elc Gra~it Ceurf, and ~p1iuN wilh Tax A~o~.)
~ ~ ~3 ~189 2403
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