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Deciaration ot Domicile and Citise~ship
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TO THE STATE AND COUNTY TAX ASSESSOR, -
S~ . lUC1E COUNTY, FlOR10A: q O La r~
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This is my declaration of Domicile and Citizenship in the State of Flo~ida that I am filing this day in accordance and ;
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~n co~formity with Chapter 222, Section 2Z2.17, Florida Statutes. '
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I was formerl a t al resident of ._VY ~~l/~~_ v `
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Y e9 -
(City) (State) ~
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~ ~ s ~ _ _ _ _ _ _ . However 1 have chan ed m domivle `
and I resided at~_ ~/QQQ-~- 9 Y ' '
(Street and Numbe~)
r n h ve been a bona fide resident of the State of Florida since l--~ - - day of -
o and am a d a ~
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_ _ _ _ , 19
7~, and 1 reside at - 8~ - - -
- . _ _ _ (Street d Number
FORT PIERCE, SAINT lUC1E COUNTY, aORIDA «
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 facis, such as sate of property or business, or relinquishment of empioyment
at former domicile, removal of family to new domicile, purchase of home, etc.)
FIlfO ANO RECqRDE
~,y~~~j~,~Q.,!!r ~ ~ ST. I~lQCERCPOITRAE ~
CLERK CIRCUIT COUII
RECORO YERIfIEO
Mu~ 19 9~ AN'? t
206 748 ~
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3 I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
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~ I fURTHER CERT{FY that 1 have no intention to return to my former domi~ite, and f intend to remain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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$ ~ hl~,~ay 1: I~~~i~oR ~ ~
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~ S~erbin t~ 5ht1 `subsc~ibed before me this ~ day of ~
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~ . ROG~R ~QlTR~15 +
~ C~t T COURT Notary Public
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~ gy ~ ' D.C. My Commission expires
.~''r...~;~• 4
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(To bs ~xecuMd in duplicate ane! oripinsl ~iled with C1Klc Grcuit Couif, and duplicat~ with Tax Ass~ssor.l
~ BOGK ~ul
~ No 13