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Decla~ation ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR. 2Q j.~t~ J
Sl. IUCIE COUNTY, FLORIDA:
This is my dectaration of Domicile and Citizenship in the State of ~lotida that 1 am filing this day in acco~dance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a legal resident of ~l~---~r_~.1 ~ - - - _ - - - - _ ! /
tCiy) (State)
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and 1 resided at _~_Q_ _ _ ~ . However I have changed my domiCile
(Street and Number)
to end am an have been a bona fide resident of the State of Florida since`~~.~ 7f _ day of
-t.. ~
_ _ ~ _ , 19~~, and 1 reside at . ~ ~ _ ~(.JC-~ I~- -
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, ftORtOA
~nd this statement is to be taken as my declaration of citizenship, act~al legal residence and domicile in the State of Florida.
(tnsert here any pertine~t facis, such as sale of property or business, or re{inquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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iT IYGE COYMT~ s
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~ I FURTHER ~HtTIFY that I will comply with all other requirements of a leyal residant of this State.
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~ I FURTHER CERTIFY that 1 have no intention to return to my former domitile, and I intend to remain in FORT ~
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. E
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q `~v,,~ cGi~ ~ (Name)
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~ Sworn to end subscribed before me this,~t1'~ll~ day of _ , 19~~
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~ RoaHe ro~Tw?s - - -
,5 CIRCUIT COURT ~ ~ Notary Public
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~ aY --~~~~Ly~~__( ZE~_~ D.C. My Commission expires -
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~ (To b~ ~x~cut~d in duplicat~ •nd oripinal fil~d with CIKIt Ci~cuit Court, and dupliut~ with T~x Ass~ssor.)
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