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Declaration of Domicile and Citizenship i
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TO THE STATE AND COUNTY TAX ASSESSOR, ~
51. WCIE COUNTY, FLORIDA: ~ ~
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This is my declaration of Domicils and Citizenship in the State of Florida that 1 am fili~g this day in accordance and t
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in conformity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of __G~__..~
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(City) (State) ~
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r?~d 1 resided at / ~P
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(Street a~d Number)
to and am and have been a bona fide tesident of the State of Florida since a__/~ _ day of
l~ GL G~,~(~(/~---~ 19
~1., and 1 reside at ~4=4__ ~_1~•c r.rT/.~ ~ T~ -
^ (Street and Number) "
/~~tZ T ,S J. L V t' ~
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA -
and this statement is to be taken as my declaration of citize~ship, actual legal residence and domicile in the State of Flarida.
(Insert he~e 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.)
p f LED ~?KD RE~EO
:~.LtIC1E COUNn A. ~
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~'1// CIERR CI~tCUIT COUAT O
RECORD YERIf1E0
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I fURTHER CERTIFY that I will comply with all other requirements of a legal resident of thia State.
1 FURTHER CERTIFY that I have no intention to return to my fo~mer domicjle, and 1 intend to remain in fORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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' (Name)
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~wo~n to anc~c~te~bsa`ib~i before me this ~ Q day of , 19~
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~~l~ Notary Public
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By ~ .C. My Commission expires
(To b~ ~x~cut~d in dupliut~ and ori~inal fil~d wlth Cl~rk Grcuit Court, •nd dupliaN with Tax Ass~s~o~.)
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