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Declaration ot Domicile and Citizenship !
TO THE STATE AND COUNTY TAX ASSESSOR,
~ Sl. LUCIE COUNTY; FLORIDA:
This is my dectaration of Domicile and Citizenship in the State of Flo~ida that 1 am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of _y~Z~ff2!' ~ ~
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;ty) (State)
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and I resided at ~ ~ . However I have changed my domiCile
(Street and Number) (
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ro and am and have been a bona fide resident of the State of Florida since _ ~ - day of
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- - - - - _ 19?f _ , and I reside at r ~ - - - -
' y (Street and N}~mbe~)
~ri~~u''~Q- oy Q-.-vt~
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA
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 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.)
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~ ~ F~LEO I'.ND RECORDED i
~ ~T. LUCIE C~Ut:TY, FLA_
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214932
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i ':LrQ.~ C~f?CUIT CQURT
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I FURTHER CERTIFY that I will comply with ell other requirements of a legal resident of this State.
t FURTHER CERTIFY that I have no intention to ~eturn to my former domi~ile, and I intend to remain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanenlly.
G/~,~
~ (Name)
~.ky ~ay e.
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~ . .Sw / to and.wl~stribed before me this ---_1 day of --__--"f " , iy~.
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~ ROG~-.~OiTL?s -
~ CLERK CIRCUIT COURT Notary Public +
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~ By ~ _ _ _ .C. My Commission expi~es
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~ (To b~ ~xecvt~d in duplicate snd oripin~l filsd with Cl~rk Circuit Court, and dupliut~ with T~x Ass~ssor.)
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