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Declaratio~ at Do~niclle and Citisenship
TO THE : TATE ANU COUNTY TAX ASSESSOR. 214262
Sl. IUCIE COUNTY, FIORIDA~
rf~s ~s my declaration of Dom~ale and Citizenship in the State of Florida that I am filing this day in accordance anr!
~n conformity with ChaptPr ?~2, Section 222. 7, Florida Statutes
I was formerly a leqal resident of ~C~~- s'~~!`_G'~~---
(City) (State)
and I resided at /7 _<«F ~~l. _ However I have changed my domic,ile
• (Street and NurnSer)
ro and am a~d have been a bona fide resident of the State of Florida since ~ day of
~f ,
, 19_~~ , and 1 reside at _ . 4l ~ ~ -
(Street and N ber) •
~l•t-c7 .Cl~!
FORT PIERCE, SAINT LUCIE COUNTY. fLORIDA
and this statement ~s to be taken as my declaration of citizenship, actual legal residence and domicile in the State ot Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, rzmoval of family to new domicile, purchase of home, etc.)
t_ L_<f i !ti ;(~~l~'~ •
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~~42 C. ~E7/» t t • sc ~
FIl:O A~f RECOROEO
ST. LUGIL LOUliTY FIA.
ROi,E.°. 'O~;RAS
CIERK CInCU1T COURT '~L
RfCORp VE41FIE0~
Auc 19 I I o2 bH'T I
214262
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1 FURTHER CERTIFY that I will comply with all other requirements of a legal ~esident of this State.
~ 1 FURTHER CERTIFY tha! I have no intention to retvrn to my fcrmer domicjle, and 1 inlend !o remain in FORT
PIERCE, SAlNT IUCIE COUNTY, FLORIDA, permanently.
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e (Name)
~d mu?~ io j~Q NT E~o
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a Sworn to e(~d subxribed before me this day of _S CC~ ~ ~c~s.~ 19_
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~ - ' ,~OITRAS
CIRCUIT COURT Notary Public
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~ By f~!_~!""`-.~- D.C. My Commission expires _
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; (To be executed in duplicate and original filed with Cl~rk Cirtuit Couirt, snd dupliute with Tax Ass~ssor.)
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