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Deciaration ot Don~iciie and Citize~ship
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TO THE STATE AND COUNTY YAX ASSESSOR, y O~~~ 1 i
51. IUCIE COUNTY, FIORI~A: ~
This is my declaration of ~omicile and Citizenship in the State of Florida that I am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of ~~-~-~1 --L~~~~~~=--- s
(C;ty (State)
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and 1 resided at _ _ _ . Howeve~ I have changed my domiCile
(Street and Number)
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to and am and have been a bona fide resident of the State of Florida siRCe _ _~C1~b~-~Gt.-------- day of i
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_ . _ _ _ . _ , 19~l1, and 1 reside at z -
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(Street Number) i
FORT PIERCE, SAINT IUCIE COUNTY, FLORIDA ~ ~
and this stateme~t is to be taken as my declaration of citizenship, adual 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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f11E0 A~D REC
fT. tYCtE COilNTY~
ROCER POIT~AE ~
CIERR CiRCUfT C61MT ~Q.
RECORD IIERiF1EG~
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~ 20~847
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~ 1 FURTHER CERTIFY that 1 will comply with all other requirements of a legal resident of this State.
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~ I FURTHER CERTIFY that I have no intention to return to my former domiG~e, and I intend to remain in FORT j
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~ PiERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
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~ (Name) ~!c /Y/e cs y • .
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(Address)
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~ . ,.Sw~or~~nd suburibed before me this ~ day of ~ ~ 19~
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:y - • ~ RT Notary Public ~
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~ By~. ~ - ''CL~~*- D.C. My Commission expires
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(1s~ it ~x~cut~d in dupliut~ and oripinal ~il~d wfth CI~?k GrcuFt Court, and dupliut~ with Tax Ass~swr.) ~
~ „ d~~~ 191 y31 ~
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