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Decla~ation ot Domicile and Citi:enship ~
~ ~0612A
TO THE STATE AND COUNTY TAX ASiES~OR.
~1 IUCIC COUNTY, FlOR1~A
Th~s ~s my dedarat~on ot ~om~ule and Cit~=ensh~ in the State of Floride the~ I am fil~n this da ~n accordance end ~
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,n conform~ty w~th Chapter Section ???.17, flor~de Stetutes t
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I was formerly a legei resident of ~E/[ G-~IV ~L ~`f~ tif _F ~l,' ~
(City) (State) ~
rnd I res~ded at -`~~O ~fJ [7__V _F Nowever 1 have changrd my domi~ile
~ (Street and Number)
ro and am and have been a bo~a fide resident of the State of Flo~idn since r 7 day of
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f~'1 f~RC f~ , 19~~ , and I ~eside at t~'.S1 ~AIeRf~.~_~~~! ~~1 S' .
(Street and~Number)
FORT PIERCE, SAINT Ll~G1E COUNTY, RORI~A ~
and this statement is to be taken as my declaration of citizenship, actual fegal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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A ti' ti' ~e .n ~t ti' IIv~L
~ / FILEO ANO RE
1~! ~ 1 ~ N R Y I Q s ~e in x~ iv /`5' sT. R~ER Pa~rt~~' y~,
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~ 1~i l4 r I~ S ( 0~ R? I- f- o~ f A1 Iq 1" /Z- RECORO vER~F1E0 ~
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~ I fURTHER CERTIfY that I will comply with al! other requirements of a leyal residant of tfiis State. ~
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~ I FURTHER CERTIFY that 1 have no intention to return to my former domicjle, and I intend to remain in FORT ~
~ PIERCE, SA'l~tt~CtE COUNTY, FLORIDA, perrrsanently_ 30AN ~u ~Fj~ AN
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- . ;t9 C. !
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; , . = .357 BARR AC ~o u~H ST, F.~ P~etc;Fi~l~~ ~
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~ Swom to and subscr'ebed before me this ~ day of - ,_i , 19~.
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ROGER POITRAS
~ CIRCUIT CO T ' Notary Public
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aY ~ - D.C. My Commission expi~es
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Ro b~ ~x~cvtsd in dupliu» and oripi~af fil~d with Clak Grcuit Covrt, and dupliut~ with Tuc Ass~ssor.)
~ R i90 278~ ~
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