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DeclBration ot Domicile and Citisenship ~ ~
TO THE STATE ANO COUNTY TAX ASSESSOR, 214431
51. IUCIE COUNTY, FlORIOA: ~
This is my declaration of Domicile and ~itizenship in the State of Florida that 1 am filing this day in accordance and f
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~n confo~mity with Chapter 222, Sectio~ 2Z2.17, Fioride Statutes.
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1 was formerly a legal resident of ~ . ~ - - - - '
(City) (Stat
and 1 ~esided at l~G~ ?~.~_G.1-+~L_~s~~~~,._S~-1~.~~ i' •~~Wever I have changed my domitile
(Street and Number) ~
to and am and have been a bona fide reside~t of the State of fforida since _ day of ~
_ _ . _ 19_~ ~ , and 1 reside at _ ~ ~ ~ - -
' (Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA ,
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property o~ business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.) `
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`~Q~C s~~LC~G ~
~ F LEO ANO RECORDE
~(,i'~~~~ f~ 5~. LUCIE CCUNTY fl~
/ ~J`~..(~
` / ROCER POITRAf
~ , CLERK CI+~CUIT COURT
RECORO VERIFIEO
Au~ 1~1 I ~9 PH'11
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~14431
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I FURTHER CERTIFY that 1 will comply with all other requirements of a tegal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domicjle, and I intend to ~emain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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8tt-/.1,0.~ (Nam~. ~obcaTS
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- ~i;;~.~;~',- (Address)
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Swom to-ai~subsuibed before me this day of ~ , 19~
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~ R~~ ~COURT Notary Public
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gy D.C. My Commission expires ~
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(To b~ ~x~cvt~d in dupliut~ snd oriqind Hl~d with G~rlc Grcuh Court, and duplicat~ witl~ Tax Ass~s~.)
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