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Declaration ot Don~IciEe and Citizenship
TU THE STATE AND COUNTY TAX Aa~ESSOR.
IUCIE COUNTY. F~oR~flA 214233
lh~s ~s ~ny .ieclarat~on ot Uatuule and GtiZenship in the Sta~e of Flor~da that I am fil~ng this day ~n accordance and
~n cortforrnity with Chapte~ Sec~~on ???.17, Floridr Statutes
1 was forn:erly a legal resident ef `C,`~''li~ ~~Q j(~ v' Lt~~4~i'C-~
(State)
3'
and 1 res~dec! at ~ Z~ Z/G(/~il'!'C.fl'"~'"~ ~T/t/U• However I have changed my domi~ile
(Street and Number)
ro and am and have been a bona fide resident of the State of Florida since ~(./l.L~ day of
~ J
tt,~~ , 19 ~ ~ , and 1 reside a~ ~ .I~/~~t~ .~~~~e~?ll
~ (Street and Number)
FORT PIERCE, SAINT lUC1E COUNTY, FIORIDA
and th~s statement ~s to be taken as my declaratio~~ of cihzensh~p, actuat legal res~dence and domicile in the State of Florida.
(Inserr here any pert~nent facts, such as sa:e of property or business, or relinquishment of employment
at former dom~c~0e, removal of fa~nily to new domicile, purchase of home, etc.)
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C. .~t lS-f~t-::?, -~"c ~ J r ~ !r
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FILED AhD AECOROF~
ST. lUC1E COUNT? ~
CLE KCC ~CUI Cp~p1tT C ~1~
! RECORO Y~R~FIE01~
! ~WI f Q ~
3 3s PH 1 ~
~
~14233
I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
I FURTHER CFRTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
~ ~+ERCE, SAINT LUCIE COUNTY, FIORIDA, permanently
~ x /b~-~t ' 7
~ - ~~'~t~ ~!~~^~~w-
~ t? / (Name) P ~ o t 1~
f~ ~R;,/o j n/
- .
~ ~0 ~ ~ - _
` (Address)
Swom to and svbscr~bed befere me th~s ! L~ day of ~ C<-«f 19_~~
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~ ROGER IOITRAS ~ _
~ CLEJtK CIRCUIT COURT Notary Public
~ ~ _
Ey l~ 1 .C My Commission expires
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,
~ (To b~ •x~cut~d in dupliut~ and ori~in~l fil~d with Ut?k Circuit Court, snd dupliui~ wilh Tax Ass~sso~.)
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