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O~ala~~tlon ot Oo~iail~ a~td Cltis~nshlp
~O THE STATE ANO COUNTY TAX ASSESSOR.
51 tlK1E COUNTY, ftOR10A:
Thii ~s my detluation ot Doimcile and Cit~z~nsh~p i~ 1Fk Stat~ of Florid• tha~ 1 am iil~nq th~s day in ~coord~nu ~nd
+n confwmity with Chspter 22?, Ssction ?22.17, Flo?ida Statutet.
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1 wss formerly a legsl res+de~t of - !
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and 1 ~esided at _ _ _ _ . However 1 have chsnqac! my domicjle
, (St~eet and Number)
ro snd am snd have been a bona fide rosident of the State of Florida since . _ 1. day of
~ ~
- _ 14 and 1 reside at U ~ - - - -
(Street and Number)
FORT r1ERCE, SAINT LUCIE COUNTY, RORIOA
and this statement is to be taken as my declaration of citi=enship, actual legal residence and domicile in the State of Florida.
(Insert hcre any pertinent fads, such as sale of p~operty or business, or relinquishment of employment
at former domicile, ~emoval of family to new domicile, purchase of home, etc.)
Reaident
Ft~ED ?N~ aEC~R~
:T• aOCEft PO?RI?S
Clfa
~ERIf EO C~
QECORO
EEe ~ 10 40 ~'1 t
204190
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~ I FURTHER G'HtTIFY that 1 will aomply with all other raqulrements of a leyal restdent of this State. ~
I FURTHER CERTIFY that I have no intention to retu~n to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT LUCI~ COUNTY, FLORIDA, permanently. ~Lil~B F. R ~96
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'~~•~~'~qpt~~~~tibaribed before me this day of , 19_!L_.
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ROGER MORRAS
C~CUR COtiRT Notary Public
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~ By D.C. My Commission sxpires
~
~ R~ b~ ~x~crNd i~ dypliuh aed ori~inal fil~d with CIKk Grwit Co~e1, ~nd duplicat~ wilh Tax AtN~.)
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R 18y 2y.70
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