HomeMy WebLinkAbout2422 / /
Dwcla~ation of Domicite and Citizenship
TO THE STAiE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, F~oR~oA- 214a43
Th~s ~s my declaration of Dom~c~le and Citizensh~p in the State of Florida that I am filing this day in accordance and
~n conformity with Chapter ?Y2, Section ?2?.17, Florida Statutes.
1 was formerly a legal resident of ~~~-?Ti9- - - - - - - - - - ~
(City) (State) ;
and 1 resided at %7 / L-~~~~!`4'~[/'!j'~' Howeve? 1 have changed my domitile
(St~eet and Numbe~)
p
ro and am and have been a bona fide resident of the State of Flor~da since ~ day of
~ .l~y ~ , 19_7/ , and I reside at ~~3 /jI.SS~~IS E~~ .-./~/1 _ _
(Str ~ef and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and th~s statement is to be taken as my declaration of citizenship, actuai legal residence and domicife in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
~
~ }
~.?5' - -
FItEO Ay~ kECOROFO
,f fT.LUCIE COUNTI ftA_ ~
~~'~/H ~G - BOCE~ POcTR~S ~
CLERK t~~CU1T COURt
~ / RECORO VER~FIEO~
AilC ~ 37 ~ ;
~~ic.~~s~s ~1 ;
4043 ~
~~e~ !
C //i9~ ~S
~ -
~
~ _ / 1
FF
~
~ 1 fURTHER CERTIFY that 1 will comply with all other requirements of a legal resident of this State. ~
~
t FURTHER CERTIFY that I have no intention to return to my former domicjle, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY. FLORlDA, oermanently. ~
~ !
~ /~LGf~L'a- -ff--
~ (Name) ~
~ ~e~ec~o. iQ. Cope/a~v~
~ ' ~ - {
:g . ~ ~ (Addressf~~ ~
~ ~
~ ` Sworn 'ta end subxr~bed beiore me this - - - - ! ~ _ day of _ ~ _ _ , 191~ ~
~ ~
„ ,
~ ~ ~
~ ,r'.. ~ - .
' ' ~~~~otntws _ _ - - - - - ~
" _ ~CtRCUIT COURT Notary Public ~
~ By .C. My Commission expires
~ - - ~
~ ~
~ (To b~ ~x~cut~d in dupliut~ and oripind fil~d wiib Cltrlc G~cuif Cou~f, and dupliut~ with Tax Ass~ssw.) ~
~
~ .y a~arlg4 242Z
~ . -
v ~
. -~__-Y.~._ - . . . _ . _ . _