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DeCiaration ot Domicile antl Citlzenship
TO THE STATE AND COUNTY TAX ASSESSOR, 2 0 s 91 ~
51. lUC1E COUNTY, FLORIOA:
This is my declaration of Oom~ule and Cit~zenship in the State of Florida that 1 am fil~ng this day in accordance and
~n co~formity with Chapter 222, Section 22?.17, Florida Statutes.
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I was formerly a legal resident of "~L P~?t~-7'~
J t (City) (State)
and 1 resided at j~ G EI1:~1.' _ ~f.~ .~ll' However I have changed my domi[i~e
~ (Street a~d Number)
fo and am and have been a bona fide resident of the State of Florida since ~C..' . _ day of
n
_ , 19~G, and I reside at _~~7 3 3__ _ - ~'~~"(i~~~ -
(Str and Number)
FORT PIERCE, SAINT LUClE COUNTY, FLORIDA _
and this statement is to be taken as my declaration of citizenship, actual legal ~esidence 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 all other requirements of a leyal resident of this State.
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E 1 FURTHER CERTIFY that I have no intention tu return to my former domi~ile, and I intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FIORIDA, permane~tly. ;
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~ (Name) •
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~ J~~om tq and subscribed before me this day of -___.-~~L~ 19~~.
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_ '~C,~M~ COURT l Notary Public
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d" '$Y ' ~ --~~~~L-------- D.C. My Commission expires -
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; (?o ~b~ ~x~cut~d i~ duplicat~ and oripinal filed with Cl~rk Circuft Court, and dupliut~ witF~ Tax Ass~ssor.)
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