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Declaratio~ o! Qomi~ile a~t~ ~ltiz~nship
TO THE STATE AND COUNTY TAX ASSESSOR, ~.L~.VU I
Sl. LUCIE COUNTY, FLORIDA~
Th:s is my declaration af Domicile and Citi2enship in the State of Florida that I am filing this day in accordance and -
~n conformity with Chspter 222, Section 222.17, Florida Statutes.
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1 was forme~ly a legal resident of `.'!..1.'L~.L '3ti:.li~k• - ~ - - - - - ;
~(;~ty) (State)
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and I resided at . ~ . _ ~ . ~l ~•~Lnl ~ i-~r ' • However I have changed my domicjle '
(Street and umber) s
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ro and am and have been a bona fide ~esident of the State of Florida since ` I~ day of
~ ~ y ~~~`1 ~ ?
_ , 19_ , and 1 reside at _4; ~ t_ _ ~ ~ - -
(Street and Number)
FOitT PIERCE, SAIHIT LUCIE COUNTY, ftOR10A _
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert he~e any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domiole, removal of family to new domicile, purchase of home, etc.)
Establishing residence
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<Appl~ing fQr homestea
i1LF0 AND RECp~~
zT_ WCif COYMTT R~.
Entering children in school ~~ci~cwt
c~o~t s
1tECORD YFRfF'iEO~.~..,~'~
J~ 21 9 ~ aM ~T~
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~ I FURTHER CERTIfY that 1 will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that 1 have no intention to return to my former domiule, and I intend to remain in FORT
~ PIFRCE, SAINT LUCIE Ct~UNTY, FLORIDA, permanently_
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~ (Name)
~G SS c l ~ I~_ N A?''~ M
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~ Sw~r1~i4:sf+t~ ~~ed before me this day of _ _ , 19~' ~
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~t~.~}i c . ~ l
~ ~tQ4ER POITitAS'~.~'~'_ -
~ ~IE ClRCUIT COU ~ T z Notary Pubiic
~ By - ~ ' . ~ G ~ D.C_ My Commission expires _ _
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~ (To b~ ax~cut~d in duplicate and ori~inal ~ilad with Cl~rlc Grcuit Court, ~nd dupliut~ witl~ Tax Ass~sso~.)
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BOU~
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