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Deciaration ot Domicile and Citisenshlp
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TO THE STATE AND COUNTY TAX ASSESSOR,
51. LUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day i~ accordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was forme~ly a legal ~esident of _ _ _ ~ -
(Ciry) (State) !
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and I resided at . However I have changed my domicjle ~
(StreBt and Number) ~
to and am and have been a bona fide resident of the State of Florida since _ day ot
~ G~',~- /
- - - - - - _ 19~~! and 1 ~eside at
reet and Number)
FORT PIE1tCE, SAINT IUCIE COUNTY, fLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal reside~ce and domicile in the State of Florida.
(Inserr here any pe~tinent facts, such as ;ale of property or business, or relinquishment of employment
at former domicile, ~emoval of family to new domicile, purchase of home, etc.) f
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204`71-2
F ~Ep ANC ftECORCEO
g~.1AC1f COUM~ F~~
RCCEi~ PO~TA~'S
CLERK C1A~?E~p COUf
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; RECORO ~ER 52 ~M ~ ~
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~ I FURTHER CERTIFY that I wil) comply with all other requiremenri of a legsl resident of this State.
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I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ -~~'r_~,~~,01'~,,,a~nd wbscribed before me this ~ day of , 19?~
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~ W~ ~~,RAi
~ CIRCUIT OURT ~ Notary Public '
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~ By D.C. My Commission expires j
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~ (To b~ ~x~cut~d in dupliut~ snd oripinal Rl~d whh Cl~k Grcuit Court, and dupliu» wilh Tax Ass~ssw.) ~
800K
~ ~ R 1~ 6~7 }
~ No 13
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