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206116
DeCiaration ot Domicile and Citizenship
TQ THE STATE AND COUNTY TAX ASSESSOR,
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51. IUCIE COUNTY, FIORI~A: ~
This is my declaration of Dom~ciie and Citizenship in the State of Florida that I am fili~g this day in accordance and
~n conformity with Chapter 422, Section 222.17, Florida Statutes. ~
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I was formerly a legal resident of G81AeeVille Florida ~
- (Cityy - - - (State)
and I resided at 1~60 ~1. S. 1'Sth P18 Ce__ _ However I have changed my domiti~e
(Street and Number)
to and am and have been a bona fide residem of the State of Florida since 1 B t - day of
Yareh_ _ 1971 , and I reside at __?914__Forrest Terrac•
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, KORIDA
and this stateme~t is to be taken as my declaration of citizenship, actual lega! residence and domic~fe in ihe State of Florida.
(I~sert here any pertinent facts, such as sale of property or business, or ~elinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
residence
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ST. ~UCIE C~1M1 T~ .
Il04EA tO~~A:
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~ 1 FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
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~ I FURTHER CERTIFY that 1 have no intentiors to return to m former domiUle, and I intend to remain in FORT t
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. Q/~'`"
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? ~ C~ SJ Q ;'p - ~j (Name)
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- z~ ~s a= 2g14 Forrest Terrace, Ft. Pierce
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y : ~ ; ~i ' t 4 ~ (Address)
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~ ~~~~'Ga ~ ~ 15 th Yarch T1
~ ~~iUllq*~pn2~ subx~ibed before me this day of , 19 ~
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; ROGER POITRAS -
~ CIRCU CO~ Notary Public
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~ By ~t' D.C_ My Commission expires
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- (To b~ ~x~cuted in dupliut~ snd oripinsl filed with C{~rk G?cuit Court, and dupiiuN with Tax Ass~stor.)
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