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DeCiaration ot Domicile and Citiz~a~ship
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TO THE STATE Ah~ tOUNTY TAX ASSESSOR,
51. IUCIE COUNTY, FtOR1DA:
Th~s ~s my declaration of Dom~c~le and C~t~zensh~p in the State of Florida that I am filmg this day in accordance and
~n conformity with Chapter 22~, Section ?22,17, Florida Statutes.
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t was former~y a legal reside~t of _ _ - - _ -
(Ciry) (State)
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and t resided at ~ C~ _ rl''~~ "L,~ However I have changed my domicale
(St~eet and Number)
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fo and am and have been a bona fide resident of the State of Florida since / day of '
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, 19_~~ . and I reside at °'2~~ ~ ~ ~6
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(Street and Number)
FORT MERCE, SAINT tUC1E COUNTY, RORIOA
and this statement ~s to be taken as my declaration of citizenship, actual legal resiclence and domicile in the State of Flo~ida.
(Insert he~e any pe~tinent facts, such as sate of property or business, or ~elinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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s~~~U~~E C.OUNIY iU.
RBCE~ POtT1Ut
CIERK CIRCi11T CO~MT
IIECORO vEll~f1E0.~.~~
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~ 1 FURTHER CERTIFY that 1 will comply with all other requirements of a le9al resident of this State.
~ 1 FURTHER CERTIFY that t have no intention to return to m former d mi 'ie n int n t
y o G, a d 1 e d o rema~n ~n FORT
~ ~fERCE, SAINT LUCiE COUNTY, FLORIDA, permanently.
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~ ; : . - J'':,,, (Name -
~ `.;.~~r ~ ~ , Yrs. H. 8obert tJanet) Sathburn
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~ ~ ~SworlL,Stt~~+d subscribed before me this ____-9 _ day of _ v"=a'~ , 19
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~ ROGER PORRAS
CIRCUIT RT Notary Public -
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~ gY - t~.C. My Commission expires
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~ (To b~ ~x~art~d in duplJcat~ and ori~ina! fil~d with CINIc Grcuit Couif, and dupliuN with Tax Asstaso?.)
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