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Decla~ation ot Domicile And Citisenship
TO T1iE STAiE AND COUNTY TAX ASSESSOR,
'~l LUCIE COUNTY, FIORIDA 212'749
Th~s ~s n~y declarat~o~~ of ~om;u!e and C~t~zensh~p in the S~ate of Flo~~da that I am f~l~ng th~s day ~n atcordance and
n co~~ormity with Cha~ter ??2, Section ?2?.17, Florida Statutes
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I was formerlv a legal resident of ~~l~SCI~ . ~ '3~~5~`
(C;~yt (State)
~nd I res~ded at ~`r~ ~ O~~ IC o~ Z-~ _ Nawever I have changed my domicjle
(Street and Number)
+o and a~n and have been a bona fide resident of the State of Florida since day of
f I L~ , 19 , and 1 reside at l!O ~.t L ~ r~4 !~!'_L •
(Street and Number)
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FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and th~s statement is to be taken as my declaration of c~tizenship, actual legat residence and domiale in the State of Florida.
(Inser~ here any pert~nent facts, such as sale of property or business, or relinq~ishment of employment
at fa~mer dornicile, rerroval of family to new domicile, purchase of home, etc.)
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RECORO V~
~ 23 1106 ~M'T 1
' 212`749
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I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
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I FURTHER CERTIFY that I have no intent:on to return to my former domicrle, and 1 intend to remain ir FORT
~IERCE, SAINT LUCIE COl1NTY, FLORIDA, permanently_
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~ • ~ (Name)
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~ - Phillip C Wasson
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(Address?
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Swom to and subscnbed before me this - _ _ _ day of ~ ~ _ , 19~~ .
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~ ROGER POITRAS . _ - - - - -
~ j CLERK CIRCUIT COURT Notary Public
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~ BY . - - - D.C My Commission expires - - -
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~ (To be executed in duplicate and original filed with Cle?k Circuit Court, snd duplipte wilh Tax Assessor.)
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