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Deciaration ot Ddmicile and Citisenship
TO THE STATE AND COUNTY TAX ASSESSOR,
~V `8S~
Sl. IUCIE COUNTY, FIORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in accordance and
~n conformiry with Chapte~ 222, Section ~22.17, Florida Statutes.
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I was formerly a legal reside~t of ~9~ U~~~~~ " _ L ~L" ~ / V - ( !
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(City)' (State)
~f ( o 7k ~ l~d
and 1 ~esided at _ . _ However I have changed my domiGle
(St~eet and Number)
ro and am and have been a bona fide resident of the State of Florida since S~~// I_.___ day of
~ . _ ~ ~ ~ 7 I _ , 19_ , and I reside at ~a0 ~D ~ 9 • _ VA~~ /V~,~ /9 - -
(Street and Nvmber)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
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 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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i11E0 AND RECoRot0 ~ ~
ST. lUC1E COUliTY FIA. i
ROGER POITAAs E
CLERK CIRCUIT COURT c`T k
RECORO VER1f1E0~~
APR I 9 IO 4S AN'7 ~
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~ I FURTHER CERTIFY that I will comply with all other requirements of a(eya) resident of this Stafe.
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~ I FURTHER CERTIFY that I have no intention to return to my former domicjle, and I inTend to remain in FORT
;
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanensiy_
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~ (Name) -
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•~wor~ to and,s~k~s~il~ed before me this ____1__~_._ day of L l_~_ , 19.L1 .
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GL~'ClddJlt. COURT Notary Pubtic
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h BY , i~~__` vj~- O.C. My Commission expires -
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~ (To b~ ~x~c~t~d in duplicat~ and oripinal fil~d with Cl~rk Grcuit Court, and dupliuN with Tax Ass~s~or.)
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