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Decla~atio~ ot Domicile ~~d Citise~ship 212894
TO THE STATE AND COUNTY TAX AS.~ESSOR.
Si. IUCIE COUNTY, fIORIDA:
This ~s my declara~ion of Oomiule and Citizensh~p in the State of Florida that 1 am filing this day in accordance and
,n conform~ty w~th Chapter 22?, Sect~on ?22.17, Florida Statutes.
I was formerly a legal res~dent of ~!J L!~ _ N
N~
(City) (State)
~ys.c~ lti'~~
and I resided at _ . _ However I have changed my domiti~e
(Street and Number)
+o and am and have been a bona fide resident of the State of Flori~la since SV L y 3~ ~ 97~ _ day of
i
J(%L r . 1971 , and 1 reside at ~~•f~ S. ~~O~PN L /~l/GMws~Y . ~
(Street and Number) '
FORT PIERCE, SAINT I.UCIE COUNTY, F10RIDA
and this statement is to be taken as my declaration of citizenship, actual legal :esidence and domicile in the State of Florida.
(Inser~ here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, rem~val of family to new domicile, purchase of home, etc.)
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I fURTHER CERTIFY that 1 will comply with all other requirements of a legat resident of this State.
I FURTHER CERTIFY that I hove no intention to return to my former domiule, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently.
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. . (Name)
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~ ~ SworaYo and subscnbec! before me this _ _ ~ day of , ~ ~ _ , 19L~
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~
~ IEOCER POITRAS -
~
LERK CIRCUIT COURT Notary Public
~ ~ ~
~ ~ `-l ~ ~ _ D.C. My Commission expires
~ BY - -
~ (To be sxecuted in dupliute snd original filed with Cleric Grcuii Court, and dupliute with Tsx Assessor.)
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