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Declaratio~ ot Domicile and Citizenship f
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2t)~38~
TO THE STATE AND COUNTY TAX ASSESSOR,
51. IUCIE ~OUNTY, FLORIDA:
This is my declaration of Domicile a~d ~itizenship in the State of Florida that 1 am filing this day in accordence and
~n co~formity with Chapte~ 22Z. Section 222.17, Florida Statutes.
I was forme~iy a legal ~esident of _~r~~~ ~ - ~ h~~Gf~ ~ _
~~;ty~ (Staro)
y7~c !~/~1S~TE•~r~ w R n ,
and 1 resided at However 1 have changed my domivle
(Street and Number)
to and am and have been a bona fic+~ resident of the Stste of Fiorida since --1~ day of
- n ~
o ~LCl1,BE~--_ . 19.Z1L, and I reside at ~-/V~ s'D~/D!3 'D~ - ~T /"/C/~
(Streat and Number) F'~,4
FORT ~IERCE, SAlNT lUC1E COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legat residence and domicile in the State of Horida.
(Insert he~e any pe~tinent facts, such as sale of p~operty or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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F1l,E~ ANO RECOROEO i
ST.lUC1E COUNTY F~A. ~q~ x
FiOCE~ POITRAS U
c~fRK c~~cuiT couaT
RECORD vERIF1E0~~
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~ 1 FURTHfR G'ERTIFY that I will comply with al) other requirement: of a feyal resident ot thi: State. :
I FURTHER CERTIFY that I have no intention to retum to my former domiqle, and I intend to remain in FORT
°IERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ be21 (Name) DQ n~ ~ ~ee_ srt"
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~ Svdorp.b~jid suburibed before me this `1 + day of . 19~•
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~ a: ' . G~T Notary Public
~ B - _ ` . ~ ~ D.C. M Commission expires ~
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~ (fo ~ `~s duptiaa and orianal ~t.d with Ct..lc Cirwit Cour~, and duplicat~ with Tax Ass~swr.)
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