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Declaration ot Domicile and Cit~zenship
TO THE STATE AND CGUNTY TAX ASSESSt7Q.
~l IUCIE COUNTY, fIORIDA 21"~~'45
lh~s ~s my .ieclarat~o~~ of OoR~~c~le and C~t~zensh~p ~n the Stare of Hor,da that 1 am f~l:ng th~s day ~n acco~dance and
n conform~ty w~th Chapte~ Sect~c~ l i, Florida Statutes
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1 was forneerly a fegal res~dent of _~L ~ ~ ? ' .
(City} ~ (State)
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~n~ 1 res~ded at x s ~7i~i~~ `-tYi~ ~ However I have changed my domicile
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~o and am and have been a bona f~de res~dent of the State of F~orida s~nce . l~ ~ day of
iy`~ % C/ . 19 J and 1 reside at ~ ~ / CT3r - - - ~-t~.v~~
~ Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
.~nd th6s sta?ement ~s to be taken as my deciarahon of :itizenship, actual legal reside~~ce and dom,cile ~n the State of Florida.
(Insert here any pertinent facts, su:h as sale of property or business or relinquishme~t of employment
at former dom:cite, removai of fam~ty to new domicile, purchase of home, etc.)
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FILED AND RECOROEO
ST. WCIE COUbTY ft+1. ~
ROCER PO~TRAS ~`a
CLERK CiRC81T ~OiIRi C
RECORO VER~FIfO~
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I '~1~~45
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I FURTHER CERTIFY that I wiil compty with all other requirements of a legal resident of this State.
1 FURTHER CERTIFY that I have no inre~tion to return to my former rlomiCiie, and 1 intend to remain m FORT
r~:RCE, SAINT LUCIE COUNTY, fLORIDA, permanentty
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~ , . ~ (Name1 ~ ~1, n'f ' ~ ~
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~ slu6scnbed before me th~s ~
~ Swom to an ~ _ day of c._ ~s _ , 19
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ftdGE~ ROlTRAS _
~ CLERK CIRCUIT COURT Notary Publ~c
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~ aY - --~LL~1~ * ~l _~~.C. ~Ay Comm~ssian exp~res - - - - -
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~ (To be executed in ~iupliute and eriginal filed with Clerk Circuit Cou?t, and duplicate with Tax A;sessor.)
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