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D~claration ot Domicile and Citizenahlp
TO THE SiATE AND COUNTY fAX ASSESSOR.
Si . IUC~E COUNIY. FtOR~oA Z+143~4
Th~s ~s my detiara~~on of Dom~ule and Citizenship in the State of Florida that 1 am f~ling th~s day in accordance and
~n conformity w~th Chapter ?22, Section ???.17, Flo?ida Statules ~
! was forn~erly a legal resident of ~omuc.~s _ M~~hi.g~,n-__. .
(City) (State) j
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and I res~ded at a3~3~i V~IIe~ ~R Hovvever 1 have changed my clamicale ~
(Street and Number) j
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fo and am and have been a bana fide resident of !he State of Florida s~nce ~ V'Y 3~ day of ~
r
SV`~ . 19_7~ , and I reside at ~Q ~~1~~~5_~Ve.__~_ r"1
(Street and Number)
FORT PIERCE, SAINT WCIE COUNTY, FLORIDA ~
and th~s statement ~s to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
tlnsert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of fa~~ily to new domicile, purchase of home, etc.)
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I(~ ~l aY'~ - ~-t aY ~ e fILEO AM~ RECOROEO
1 tT. ~~ERCPOIT AS ~
Y'~~ RE OR~ 1IERR
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Auc 13 II 12 AM 71
2143~4 ~
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1 FURTHER CERTIFY that 1 will comply with all other requirements of a lega) resident of this State.
I FURTNER CERTIFY that 1 have no intention to return to my former domiGle, and I intend to remain is~ FORT
?iERCE, S41NT IUUE COUNTY, FLORIDA, permanently. ~
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~ Swom W end subccr~bed before me this - 1
§ ~ - - day of - - _ - , 19~/
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~ ' C~?~M( CIR~~U Notary Public ~
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~ By ~G~ l.~l/ p'C. M m s
- y Co mission expires s
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~ ji~~ ioaalhl~ in dupliut~ and oripinal filsd with CI~?k Grcuit Court, and dupliuH with Tax Ass~ssor.) ~
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,3 g~~, 2982