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20~782
Declaration ot Domicile and Cittzenship
TO IHE STATE AND COUNTY TAX ASSESSOR, ~ i
Sl. LUCIf COUNTY, FIORI~A:
This is my declaration of Dom~cile and Citizensh~p in the State of Florida that I am filing this day in accordance a~d
~n conformity with Chapter ?22, Section 222.17, Florida Statutes.
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1 was forme~ly a legat resident of ~f/,G~~ t~~~. - ~~L~L~_~ '-~L=14~-f
(City) , (State)
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and I ~esided at ~ _ J ~l ~ l L ~ ~~z ~ ~ ~~-t- _ _ _ However I have changed my domicjle
(Streef and Number)
to and am aRd have been a bona fide resident of the State of Florida since ~/~/~1l `_Y_ _ day of
~ ! f !i 1 !~v l ~~~7_ -~L_~~~LaG ~ .s.CG S'.~ ,
_ j C _ , 19_7. , and I reside at - - - -
(Street anc! Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State ~f Flo~ida.
(Insert here any perti~ent facts, such as safe of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, ei~.)
~~S / D EpIG E ~
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fILEO 41fl IiECORpEo
aT. tKIE GQUMTY iLL
~OCER PO{T~~S
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REff~RD VERIFIEO
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I FURTIiER ~ERTIFY that I will comply with al) other requirements of a legal resident of this State. ~
I FURTHER CERTIFY that I have no intention to return to my former domic~le, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. DAVID 1[. gI.EI[Y
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~ _ ~ ~~r ~'"L_1~~?it yfy--
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~ ` J J... '.,C'~; - ~
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v `'~*i`.;°f _ (Address)
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z $v?pRi~r~•en~~ s~ibscribed before me this 9- day of 19~
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ROGER POITRAS ~
CLERK ClRCUIT OURT Notary Public
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~ By D.C. My Commission expires j
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~ (To b~ ~x~cuMd in d~pliuN and ori~inal Fl~d with Cl~rlc Circuit Court, and dupllut~ with Tax Ass~ssor.) {
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