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Oeclaration ot Domicite and Citisenship
TO THE STATE AND COUNTY TAX ASSESSOR. 214429 ~ ~
Sl. WCIE COUNTY, FLORIDA:
This ;s my declaration of Domicile and Citizenship in the State of Florida that 1 am filing ihis day in accordancs and
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~ n conformity with Chepter ?22, Section ?22. i 7, Florida Statutes. ;
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I was formerly a legal resident of ~(:~O~Y_ L"~~~`S _
~ (City) (State)
and 1 ~esided at O ~O
- - . -T~- - _ _ _ However ! have changed my domic.ile ~
(St~eet and Numbe?) ~
ro and am a~d have been a bona fide resident of the State of Florida since o-l 7C day of
19_ , and 1 reside at 7 _ _~d
X_li2 ~ ~ _ _ . - -
(Street and Number)
FORT PIERCE, SAIN? lUC1E COUNTY, FLORIDA ~
and this statement is to be take~ as my declaration of citizenship, actua! legal residence and domicile in the State of Florida.
{Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment ~
at former domicile, removal of family to new domicile, purchase of home, etc.) ~
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tf,1LED ANO RECORD~D
~ ~t-LUC~f couw~r ~,N. ~
1110CFR POlT~ ~a
d~.£RL C1RC11ft~ a
. i~El~IRD ~Rtf'~
~ .12 2~ 11!'11
• 214429
1 FURTHER CERTIFY that I will comply with all other raquirements of a leya! resident of this State.
' I FURTHER CERTIFY that I have no intention to return to my former domicjle, and 1 intend to remain in FORT
P?ERCE, SAINT LUCIE COUNTY, FLOR{DA, permanently.
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~~tM~ ~ibed before me this day of ~-1~s G--_- . 19
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RO~i ~ /CITR/1t - _ _ - -
CLFRK CiRCUR tOURT ~ Nota?y Public
BY _ ..~`!~~sf~~ - .C. My Commission expiras
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(Te b~ nacut~d in dupliut~ and ori~ind Hl~d with Clnlc G~cuh Cou~t, and dupllcat~ with Tax Ass~stor.)
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