HomeMy WebLinkAbout2983 ~ ~
Decla~ation ot Dor~niCile and Citiz~~ship
TO THE STATE AND COUNTY TAX ASSESSOR, `~1~3~,3
Sl WCIE COUNTY, FIORIDA
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Th~s ~s niy declaration of C ~m~ule and Citizenship in the State of Florida that 1 am fili~g this day in acco~dance and
~n conformity with Chapter Sect~on ?2?.17, Florida Statutes j
I was formerly a legal residens of ~~1~ arI~~II _ O~iO
(City) (State)
:nd 1 res~ded ar ~Q ~ rOf~ ~Q~~~`l ~r'~_ _-~C~ Howeve~ I have changed my domitile
(Street and Number)
fo and am and have been a bona fide resident of the State of Florida since ~~p T~~ _ day of
~u l~J~ , 19_?~ , and I reside a~ ~l/~ ~ Jf ~
(Street d Number) ;
FORT PIERCE, SAINT LUCIE COUNTY, fLORIDA
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and th~s statement is to be taken as my declaration uf otiz~nship, actual legal residence and domicile in the State of Flo~ida. ~
(Inse?t here any pert~nent facts, such as sale of property or business, or relinquishment of employment
at former dornicile, removal of family to new domicile, purchase of home, etc.)
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~P/~~~ F~lEO AN~ RECORp
~L LUCIf COUN1r ~
AOCEA POITA~~ ~
~~~K~~ RECORD VERIFI[D 4~~„~~~ '
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~`~i~rric ~ A116 j3 ~ I 06 ~N' ~ I ~
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2143~?3
I FURTHER CERTIFY that I will comply with all other requirements of a lega) ~esident of this State.
I FURTHER CERTIFY that I have no intention to return t~ my former domi~ile, and I ir~tend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ - pl~~-~._ E'k- c'~ -
~ (Name)
To A~rNE Moaa;s
` _y~c ~ iN~r/'.tG~~~
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~ (Address)
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~ Sworn b andsubu!ibed before me th~s _°~3._ _ day of _~L.c _ 19~_
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~ " ROGYiR ?QiTRASt ~ ' - - - - - - - - -
~ - . CIRWIT,~~RT ~ Notary Public
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~ By _ ~ ~ ~ .C_ My Commission expires
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~ (TO ~~XKYtld in dupliut~ and ori~inat ~il~d witF~ Cl~rk GrcuN Court, and dupliut~ with Tax Ass~ssor.j ~ `
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~ ~~pK 194 2981
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