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Declaration ot DomiCile and Citizenship ~ ~
1
TO THE STATE AND COUNTY TAX ASSESSOR,
21493'7 ~
Sl. LUCIE COUNTY, FIORIDA:
This is my declaration of Qomicile and Citize~ship in the State of Florida that 1 am filing this day i~ accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of _ , ~ -~'~--1---_
~L~'v'_"°_'_~!_~ _ _ _
(City) (State)
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and I resided at _ . ~ _ _ . _ _ . However 1 have changed my domic.ile
(Street and Number) ~
_ ri_ - ZL-- - - day of '
ro and am and have been a bona fide resident of the State of Florida since ~~~G~,,
0
i T
- _ - , 19- , and I reside at ~-_~Q 1 / w ~Y~
(Street and Number)
FORT PIERCE, SAINT tUCIE 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 any pertinent facts, such as sale of p~operty or business, or relinquishment of employment ;
at former domicile, removal of family to new domicile, purchase of home, etc.)
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I FURTHER CERTIFY that I will comp{y with all other requiremenis of a legal resident of this State,
1 FURTHER CERTIFY that 1 have no intention to ~eturn to my former domic,ile, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
. . y r,oNN~ y
, • (Name) 7-o Ne
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: (Address)
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Sworn ta and subscribed before me this _ day of 19~~,.
~ ROGER ~OITRAS -
CLERK CIRCUIT COURT~~ Notary Public
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~ By ~ D.C. My Commission expires _ ~ ~
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(To b~ ~x~cut~d in duplicat~ and ori~in~l fil~d with CI~?k Circuit Couii, and dupllut~ with Tax Ass~s~o~.) ~
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