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O~claration ot Domicil• and Citis~nship ~
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TO THE STATE AND COUNTY TAX ASSESSOR,
•Sl. WCIE COUNTY, FIORIDA:
This is my declsration of Domicile a~d Gitizenship in the Stste of Florida that 1 am fili~p this day in aoo~rdanos and
~n cor?formity with Chapte~ 222, Sectio~ 222.17, Flarida Statutes.
I was formerly a Isgal rasident of h h
(Ciry) (Stst~)
and I ~esided at ?~O I G al. _ However 1 have chan~ed my domidle
(Strs~t and Numbo~)
to snd am a~d have been a bona fide r~ident of the State of Florida sinos dar of
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. 19~, and 1 ~eside at UC l~o~ ~d~l1,1yG~~0
(Street and t~p~b~rT~`~"
I~ORT ~IERCE, SAINT LUCIE COUNTY, ~ORlDA
and this statement is to be taken as my declaration of citizenship, actusl laya) residenc~ and domicile in th~ State of Florida.
(Insert here anY pertinent facts, such as sale of prqxrty or busi~ess, or ~elinquishmsnt of employment
at former domicile, removal of family ro new rbmicile, purchase of , etc.
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208355
EO Rl10 RECOgp~
~Id{CtE COW[TY ftA.
ROCEa PoITRA!
CIERK CIRCi11T COtlAt
R[CORD VERIFIEO...~..~..
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~ I FURTHER ~'ERTIFY that I wilt oomply with al! oth~r requir~ment~ of a lepsl nsident of this Stah.
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I FURTHER CERTIFY that I have no intention to retum b my former domicjle, and 1 intend to remain in f~6Rf
PI~f,:SA1NT IUCIE COUNTY, fIORIDA, permanently_
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Swo~n to irid subsc?ibed before me this dsy of . 19 7.
ROGER rORR/?S
CIRCUR COURT Notary Public
~ 8y ~d~~ D.C. My Gommiuion expires
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(To b~ ~c~cvhd in dupliuN and eri~inal Al~d wilh Clak Cirarif Ce~A, and duplicN~ whb Tax A~.)
~19~ 142
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