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Declaration of Domicile and Citize~ship
TO THE STATE AN~ COUNTY TAX ASSESSOR, 2 0 6 313
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Sl. IUCIE COUNTY, FIORIDA:
This is my declaration of Domicite and Citizenship in the State of Florida that I am filing this day in accordance and
~n conformity with Chapter 222, Section ~2?.17, Florida Statutes.
I was formerly a legal resident of ~%J .1 ~c'<'_C
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and 1 resided at f A 1L~ f_____.___ _ However 1 have changed my domiCi~e
(Street and Number)
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to a~d am and have been a bona fide resident of the State of Florida since _ day of
_ , 19~ S, and 1 reside at _ - t-._ ~ S~ y_~T_ R~E, t/[s ~
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as saie of property or busi~ess, or relinquishment of employment
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at former domicile, removal of family to new domicile, purchase of home, etc.) ~
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i11E0 AMD RECOAOfO -
ST. LtICI[ COUMTY flA. ~
C~ERRCC RCUIT COURT
RECORO YERIFtEO~`r
_ M~u 18 10 oa ~M'TI
2 ps313
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~ I 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 intention to return to my former domicjle, and I intend to remain in FORT
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~:~l2CE, SAlNT LUClE COUNTY, ftORlDA, perrs~anenily.
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a Sworn to and.,{u~stribed before me this day of 19~.! j
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~ . ROGER•'~~dal~.. -
~ CLERI('CI~lC~N1'C~R~f V'_ , Notary Public
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By ~ D.C. My Commission expires
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(To be ~x~i1~,. '•d1i'pliub and o?i~inal ~il~d with Cl~ric Clrcuk Court, and dupliut~ witi~ Tax Ass~swr.)
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