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Oecla~ation ot Domicile and Citisenshlp
TO THE STATE ANU COUNTY TAX ASSESSOR,
51. LUCIE C~UNTY, FIORIDA: ~14264
This ~s my deciaration of Domicile and Cit~zensh~p in the State of Fiorida that I am filing this day in acco?dance and
~n conformity with Chapter ?22, Section ?22.17, Florida Statutes.
1 was formerly a ~egal resident of 'V .~?~~1~4~~-?~ _ - 1~!
~C;ty~ (State)
s
and I resided at / ~~h~~ However 1 have changed my domiGile `
(Street and Number)
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ro and am and have been a bona fide resident of the State of Florida since - day of
t~~. 7 ~3~~~~ ~csf~~vI/ .
~ , 19_ ~ , and I reside at . . _]C- _
(Street and Number;
FORT PIERCE, SAINT LUCIE COUNTY, flOR10A
a~d this stateme~.• be taken as my declaration of citizenship, actual legal residence a~d domiciie in the State of Florida.
(Inser~ here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of femily to new domicile, pu~chase of home, etc.)
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~~L`~C 7 Lr.~ s . / -Qc <CS x 7 " _
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FI~EQ A!iD RfCOR0E0
' SL WCIE COUNri fU1.
~ ROCf R P~ITlUS
~ CLERK CIRCUIt COUAT
i ~ REcnon YE~!~lE~ ~ U
~ A~ ~g l~ AM'1~
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I FURTHER CERTIFY that I will comp~y with all other requirement~ of a legal resident of this State.
~ 1 FURTHER CERTIFY that t have no intention to return to my former domir,ile, and I intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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$ Ra 1 ph C~~~i~on
~ ~~Jl(D __~(CS~:~I[t j~ _~c~l
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, , (Address)
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1~ - day of ~ _ _ 19L-
~ orn.~:and subscr~bed before me this ~~''z' _ _ / .
~ y: - - -
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~ R POITRAS _ - - - - - -
~ %~ERK CIRCUIT COURT Notary Public
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~ By ~~__'~`,'.`'e'__ _ D.C. My Commission expires _ _
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~ (To 6e executed in duplicate and origioal ~iled with Cl~rk Grcuit Court, and duplicste with T~x Assessor.)
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R ~ ~.94 2788
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