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Declaration ot Domicile and Citizenship 2 0 5 7 5 0
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY, FLORIOA: ,
This is my declaration of Domicile and Citizenship in the State of Florida that I am fili~g this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of g-Ja~-c~-:--d~~!
(Ciry) (State)
and 1 resided at ,r~~•; y7 ~~~~-~~`t However I have changed my domiGile ~
(Street and Number)
to and am a~d have been a bona fide resident of the State of Florida since • J?-~~-~ day of
l ~ a"'~ . 19_'C . , and I reside at ~
. ~ _u~-~~ ~'Y-~ ~ .
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. (Street and Number)
FORT PIERCE, SAIN? tUC1E COUNTY, fLORIDA
and this statement is to be taken as my declaration of citize~ship, actual legal residence and domicile in the State of Florida_
(Insert here any pertinent facts, such as sale of p~operty or busi~ess, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.) .
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~ I FURTHER CERTIFY that I will comply with all other requirements of a(egal resident of this State.
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~ I FURTHER CERTIFY that 1 have no intention to return to my former domi~ile, and I intend to remain in FORT
~ FIERCE, SAINT IUCIE COUNTY, FLORIDA, permanently. j
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~ Q~v+~.-ut-- 1 ?t :~c ~~-~-~-a~-~7. ;
~ (Name) Connie Mae Young
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Sworn te and wb;tribed before me this day of , 19
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- ~ QO~~ PO~T~11A~' -
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~ CIRCUtT;t~URT Notary Public
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~ 8y _ _ D.C. My Commission expires
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€ 0 1~ ~~vf~'in duplicat~ and ori~inal filsd with Cl~rk Circuit Courl, and dupliuts with Tax Ass~sso~.)
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