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Declaration of Domicile and Citisenship :
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TO THE STATE AND COUNTY TAX ASSESSOR, ~ ~1S014
Sl. WCIE ~OUNTY, FLORIDA: ~
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This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in accordance and i
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of ...____1~~~~-- _ ;
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(CiN) (State)
and I resided at __~~1_S . G$~ ~~eQ_~___ . However I have changed my domiCile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since _!~'__'3 _ day of
0.~~t~?~'4' 19
~1~ , and I reside at~Q.L_-- ---QL'SiLl` '~Q~~
(Stteet and Number)
FORT PIERCE, SAINT LUCIE COUNTY, fLOR10A
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here a~y pertinent facts, such as sale of property or business, o~ 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 comply with all other requirements of a leyal resident of this State.
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I FURTHER CERTIFY that I have no intention to return to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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- (Name) P~rR ls ~ ~
. . ~?eNN iE
, ~l ol ~
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~ (Address)
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. ~ Sworn t0.~,~subscribed before me this day of !5~
~ . 19~.
r'~ ,`d; .
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CLERK CIRCUIT OURT Notary Public =
By ~ D.C. My Commission expires ~
(To b~ ~xecut~d in dupliute and original filsd with Cltrlc Grcuit Court, and dupliut~ with Tax Ass~sior.)
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~ a 600K ~95 PACE 87~ '
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