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214619 DeCia~ation ot DOmiCile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY, FLORI~A: ~
This is my declaration of Dqmicile and Citize~ship in the State of Florida that I am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of • • - - - ~ ' ~
~ty~ (State)
p / ~ `
and I ~esided at f!~ _1D~_ - - Howeve~ I have changed my domiCile ~
(Street and Numbe~)
to and am and have been a bona fide resident of the State of Florida since ~G~• a~~- day of ~
;
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19 and 1 reside at T , t
- -
~ (Street and Number~
O ~jd_ ~jl'~~
fORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
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and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here a~y pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removat of family to new domicile, purchase of home, etc.)
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' F11E01~N0 REC@RDEO
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>~'f~t~ aoaEa Pornu?s
~ CLfRQ C~RCUIT COIMT
AECORQ 11ERIf1E0~.~i~L
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214619
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I FURTHER CERTIFY that I will comply with all other ~equirements of a legal resident of tfiis State.
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I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently.
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• (Name)
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~ Swa~ fp ~`subscribed before me this _~`O day of ---E~ ' 19--~
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ROGER rO1TRAS - - _ _
CLERK CIRCUIT COURT Notary Public
g ~ _~C~~~ .C. My Commission expires _
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(To b~ ~x~cut~d in dupliut~ •nd ori~inal. fil~d wHh Gsrlc Circuit Cour1, and dupliuts wlth Tax Aswsw~.)
„ ~ 6~~~?~ 1~5 PAGE 321
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