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Decla~ation ot Domiciie and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, ~ O~~j '
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~l. lUC1E COUNTY, FIORIDA:
This ~s my declarat~on of Dom~cile and Cit~zenship in the State of Flo~~da that 1 am fil~ng this day in accordance and
n conformity with Chapte~ ?22, Section 222.17, Flo~ida Statutes.
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! was formerly a legaf resident of ~(J""~~r-~ • ~ - _ ~
(Ciry) (State)
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and I resided at _ _ ! ~ _ ' _ ~1~- - _ . However I have changed my domiu~e
• ~ (Street and Number) ~
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~o and am a~d have been•a bona fide resident of the State of Florida since ~Q.~ ~.~r" 7~7 _ day of
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_ . 19-- , and 1 reside at S L- - - - - -
(Sireet and Number)
FORT FIERCE, SAINT LUCiE COUNTY, FtORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicite in the State of Fiorida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of emptoyment
at former domiciie, removal of famify to new domicile, purchase of home, etc.)
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FtLE~ AMD RECpROEp ?
tT.lUC1E COUMTY flA. ~
!lOCER POITRAS ~
ClER1I CIRCUIT 001M ~
RECOAO YERIFIEO ~
1~ 16 2 a PM'tl
~ ~ 206711
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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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~ 1 FURTHER CERTIFY that 1 have no intention to return to my former domic,ile, and I intend to remain in FaRT
~ ~tERCE, SAINT LUUE COUNTY, FLORIDA, permanentiy.
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~ X~~!" Sr~-Y ~'S~L.~i~ '
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H (Name)
C Ic9~?oR~f
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' Swcm to and sut~,t~ before me th~s ~y _ day of _ G _ _ _ _ _ 19_~~.
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ROGER:~~J~' ~ - - _ - - - - - - -
CLERK tIR~l~'~ O. Notary Public
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8y ___~,t~: ' D.C. My Commission expires - . _ _ - _ -
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(To b~ ~x~cut~d
i~w~~ ~nd ori~ind fil~d with GNk Grcuit Court, and dupliut~ with Tax Ass~ssor.)
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g~191 704
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