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Decla~atlon ot Domicila and Citi:~nshlp i
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. lUC1E ~OUNTY, FLORI~A:
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This is my declarotion of Oomicile and Citizenship in ths State of Florida that I am filiny this day in acoo~dance and ~
in oor~formity with Chapter 222, Section 222.17, Florida Statutes.
I was forma~ly a legal ~esident of ~XAN ~'r~C M~LA~n~D _
(City) (Staro)
and 1 ~esided at 3~s'Z _$Rl NKLSy 2 1~. ~wever I have changed my domiCile
(Street and Numbe~) ~
to and am and have bee~ a bona fide resident of the State of Florida since _.3.~ ~RY_ day of
- 19?L, and I reside at /O7 S~-` FLG~ SST~ .
(Street and Number)
~oRr Sr. L u ~ ~ E
FORT ~IERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Flo~ida.
(Insert here a~y pc~tinent facts, such as sale of propery or busineu, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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~ 1 FURTHER CHtTIFY tlwt I will aomply with all other rsquirementt of a leyal resident of this State.
I FURTHER CERTIFY that 1 have no intention to retum to my former damiGle, and I intend to_remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
. f-. O.~J.Q ~ 1~.QA..~~ ~ /U .
~ ~ (Name)
~ _ Psal L. D~ls~~, 3r.
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~ - (Address)
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~ Swwn t~~, ~ ,,.l~#Ore me this 8ti~ day of _f+~ , 19~1_.
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~ . ' ~ , Notary Public
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~ By D.C. My ~ommission expires
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~ R° bi~.., and ori~ieal Rl~d with Cl~elc prarM Cour~, and duplieat~ with Tan Asw~or.)
~ So~ 1~2 ~!~09
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