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Oeclaration ot Domicile and Citizenship ~
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TO THE STATE ANU COUNTY TAX ASSESSOR,
Sl . IUCIE COUNTY, FLORIDA: ~ ~ ~99/
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in actordante and ti
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of - ~Q~_--- _ - _ - -
(Ciry) - ~ (S~efe~---
and 1 resided at _~~Q 9 Nowever 1 have changed my domiGile
(Street and Number) ~
to and am and have been a bona fide resident of the State of Florida since day of '
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- - ~~-~lt _ _ , 19_.7~ , and I ~eside at _ ~1 * _ _-1..~---~~~. _ - . _ ~ i
y . (Sireet and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and th~s statement is to be taken as my declaratio~ of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here 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.) "
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I FURTHER CERTIFY that 1 will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domic,ile, and 1 intend to remain in FORT
PIERCE, SAINT lUC1E COUNTY, FLORIDA, permanently.
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C'`'"!"`'` (Name) 1// N v 4?- d
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' •.,S.w41~,Ie~aitc~~subscribed before me this day of , 19~.
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ROGER POITRAS _
~ CLERK CIRCUIT COURT Notary Public
~ By D.C. My Commission expires
(To be ~xecuhd in duplicste sed original filsd whh Cl~rk Grcuit Cou~, and duplicat~ with Tax Ass~stor.)
aooK 195 PACE 834
No. 13
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