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Decla~ation ot ~omicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR. 214144
Sl. IUCIE COUNTY, FLORIDA:
This is my declaration of Oom~cile and Cit~zenship in the Sta~e of Florida that 1 am fiting tl~~s day in acco~dance and 3
~n conformity with Chapter 222, Section 222.17, Flo~ida Statutes.
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I was forme:~y a legal resident :~i ~ _ _ _~1l~!~-. _ _ _ _ -
(Ciy) tate)
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and 1 resided at _ _ _ ' _ - _ _ _ Howeve~ I have changed my domiGile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ~7 - day of
. ~ G ,o • ~ ~
- - - - . , 19-- - , and I reside at ~ ~ 1~~ ` - - ~ - -
(Street and Number) '
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FORT PIERCE, SAINT !!!C!~ COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile 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.)
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214144
1 FURTHER CERTIFY that 1 wil) comply with al) other requirements of a leyal resident of this State.
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i ~~2iHr~2 C:Ei2TlEY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~!7 C O (Name) ~~55 F ~
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(Address)
.Sworq.to an~:;i~bscribed before me this _ day of , 1911..
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` RQ~ ~ I~OITR~?. , - -
' ,t;fR~Uf~~OURT Notary Public
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By D.C. My Commission expires
- (To b~ ~xecut~d in duplicate snd oripioal fil~d with Gl~rk G~cuit Court, snd duplicat~ with Tsx Ass~s*or.)
°Yi94 ~5~5
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