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Oeclaration ot Domlcile and Citiz~nship
_ 211 ~~1 ;
TO THE STATE AND COUNTY TAX ASSESSOR, j
Sl. IUCI~ ~OUNTY, FIORIDA: E
This is my declaration of Domicile a~d Citizenship in the State of Florida that 1 sm filing this day in aooordance a~d
i~ conformity with Chapter 222, Section 222.1,7_Florids Statutes.
1 was formerly a legal residen! of _~_~a~~~ W 1~ ~Lw ~D r~
(City) (Stat~e)
and I resided at _1L_~_ V e 1r' a k e~___ Hcwever I have changed my domiGl~e
(Street and Number)
to and am and have been a bona fide ~eside~t of the State of Florida since . day of
~1'i - ~ 9~~, and ~ re:~de ar 1~f Z 2 3 SG U.l k e w o o~ ~ r k~ r.
(Strea: and Number)
FORT PtERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my decla~ation of citizenship, actual legal res~dence and domicile in the Stab of Horids.
(Insert here any pe~tinent fads, such as sale of properry or busineu, or relinquishment of employment ~
at former domicile, removal of family to new domicile, purchsse of h~me, etc.)
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211~~i
JLEO ~NO RECOR
T: ~UCIE COUNTY ~ ~
OCER POITRA= ~
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I FURTHER CERTIfIF that I will comply with all other rsquirements of a leyal resident of this State.
I FURTHER CERTtfY that 1 have no intention to return to my former domiCile, and I intend f~reinain in FORT
PIERCE, SAINT LUCtE COUNTY, FLORIDA, permanently.
~t ; : . . . (Name)
. ~ - Robert l~ Patchen
. . (Address)
= ~ ' _ rS~
^'Swom ~o~arrd subscribed beforc me this day of , 1~~ .
- ROGER rO1TRAS - ~
CIRCUIT COURT _ Notary Pe:blic ~
~;y~- ~
8y ~'<<'~' ~~'''`'~'G`~ D.C. My Commission expires ~
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(To b~ sx~cut~d in dupliuta ~nd ori~inal ~'il~d wilh CIKIc Grwit Cowi, and duplical~ wilh Tax Ass~or.) !
8U~ 19~ ~~~b