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Decfaration ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR.
51. WCIE COUNTY, FIORIDA: ' q O S,1 1 O
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This ~s rny declarahon of Dom~c~le and Citizensh~p in the State of Florida that I am fil~ng this day in accordance and
,n conformity with Chapter 222. Section 222.17, Florida Statutes
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I was formerly a lega! reside+it of ~,~14 :
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` (City) (Sfate)
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and 1 resided at C~ t~ t'- ~ 2- However I have changed my domicjle
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To and am and have been a bona fide ~esident of the State of Florida since ~ ~ f- day of ~
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f ~ t , 19 ~ , and I reside at , _ •1 ~ - ~ ` ~
(Street and Number) !
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FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
an~ this statement ~s 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 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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~ I FURTHER CERTIFY that I will comply with al) 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 domiGle, and I intend to remain in FORT ~
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~ PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently.
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n Swom to and subscribed before me this day of 4-h- 19~f .
ROGER POIiRASc -
' CLERK CIRCUFT COURT Notary Public
By _ ~ _ L2L4 ~ D.C. My Commission expires _ _
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- (To be executed in duplicate and origina{ filed witfi Clsrk Circuit Court, and duplicate with Tax Assessor.) `
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