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Declaration ot Domicile and Citisenship
TO TNE STATE AND COUNTY TAX ASSESSOR, 2~~ z 5 0
Sl. IUCiE COUNTY, FIORIDA
This ~s my declarat~on of Domicile and Citizenship in the State of Florida that 1 am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of
(City) State) ;
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and I resided at ~1 ~ ti`~" However 1 have changed my domiCile
(Street and Numbe~) '
to and am and have 6een a bona fide resident of the State of Florida since ~~?~~'LL~ h ~ ~ T l LC _ day ot
_ , 19_ , and I reside at ~ ~ ~ _ <~.)r"ut~ ~~`~11"~- u
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this staten,ent is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Inser~ 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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~ S . LUC{E COUMtY
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CIERK CIRCUIT S 4
RECORO YERIFtEO ~
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~ 1 FURTHER CERTIFY that 1 will comply with all othe~ requirements of a leflal resident of this State.
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~ I FURTHER CERTIFY that I have no intention to return to my former domic,ile, and I intend to remain in FORT
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~ s~IERCE, SAINT LUCIE COUNTY, FLORlDA, permaneMly.
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a (Name) :'r7i = c~s r~'
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= ~ Sw~rn' b and'4C~aibed before me this _ ~ day of . ~r i 9_..~_1 .
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' ~.ROOER POIT '
~ CIR ~ , - - - Notary Public _ -
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BY ` - D.C. My Commission expires
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(To b~ ~x~cut~d i~ dupliut~ and o?iginal fil~d wifh Cl~~ic Grcvit Court, and dupliut~ witl~ Tax Ass~ssor.)
~ r~ ~ 3 YooK 190 2955
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