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DeClaration ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, ~
Sl. LUCIE COUNTY, FIORIDA:
This is my declaration of ~omicile and Citizenship in the State of Florida that 1 am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a legal resident of _StOII9Wt11 North Carolina
(Ciry) (State)
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and t resided at - - _ . . BOX ~2--- _ - - - However 1 heve changed my domitile :
(Street and Number) ~
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to and am and have been a bona fide resident of the State of Florida since _ 12th y ~
_ - - - - da ot ~
February_ 1971.., and I reside at 501 S. _Indian River Drive ~
' (Street and Number) ~
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actuat legal residente and domicile in ihe State of florida.
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(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of famity to new domicile, purchase of home, etc.)
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(School Children)
2(~47'2i
f1~E0 ANO RECOROEO
April Zove - 6th Grade st. ~ucie couNtr Ft~. ;
CIERK C RCUIT COUItT
l~arilyn Kyde - 2nd Grade RECORO VERIFIED----~~~-
ffe 16 I ~ PN'll
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~ I FlJRTHER CERTIFlf thst I will oomply with all other requirements of a leyal resident of this State.
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~ 1 FURTHER CERTIFY that 1 have no intention to ret~r~ to my former domiGle, and 1 intend to remain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently. B1111e D1~IIri
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(Name)
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~ Swom to'and subscribed before me this ~ 16th day of i~ebruary ~ ~9 `~1
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8y • . D.C. My Commission expires
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~ Ro bi'~'• ',•j~ :,~;d~fi~~N'and oripinal Al~d vrifh Cbrlc CircuN Cour~, and dupliut~ with Tax Ass~ssor.)
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