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Declaratlo~ ot Domicile a~d Citizenship
TO THE STATE AND GOUNTY TAX ASSESSOR,
Sl. lUC1E COUNTY, FLORIDA:
This is my declarotion of Domicile and Citizenship in the State of Florida that 1 am filing this day i~ accordante and
in conformiy with Chapter 222, Section 222.17, Florida Statutes. ~
I was formerly a iegal resident of - j
(City) (State) '
'i'~Q 4~~~ However 1 have chan ed m domitile
and 1 resided at - . ~ - - ~ 9 Y
(Street and Number)
to and am a~d have been a bona fide resident of the State of Florida since day of
- 19
/ and I ~eside at ~ ~ d / _
(Sireet and umber)
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA
a~d 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 fatts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.) -
C4..(/~-~- ~i~~./
f ~ED AkC RECORi~E~
a~. ~uc~E couMtr L
R4CE~ POtTAAS
RECORO ~ER F ED COUp7
- ~ 3` ~p la ~N'T 1
Ii
i 2'14853
~
I FURTHER CERTIFY that I will comply witfi all other ~equirements of a leyal resident of this State.
1 FURTHER CERTtFY that 1 have no intention to return to my former domiGile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently.
(Name) S~Q~y.Qtd~ ~
_ / / -
~ (Address)
- 6iN~~~, and suburibed before me this day of ____l~~-LG . 19~
; ~ . C~- .
G:~
3 ,
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~~~'.~G,I.TRAS
:!a~ ~ ~4`~~ i~K.~llj COURT Notary Public
M-:. - .
. ~ ~
D.C. My Commission expires
. i;~i f':~ `
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(To bi ix~cvl~d in duplicat~ and oripinal Fl~d witl~ Cl~~lc Grarit Court, and duplicat~ wi~ Tax Ass~swr.)
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