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Declaration ot Domicile and Citize~shtp
• 70 tHE STATE AN~ COUNTY TAX ASSESSOR, '
Sl. WCIE COUNTY, FIORIDA: 215U15
This is my decta~ation of Oomicile and Citi:enship in the Stat~ of Florid• thN I~m filinp this day in acoord~nc~ ~nd
~n conformity wi~h Chapter 222, Section 22~.17, Florids Statutes.
1 was forme~ly a Ipel resident of , ~
(Ciy) (St~t~)
Js,~a2 ot ` ,c.2z -
and i re:idad at ~ How~v~r 1 have d?anqsd my domitili
(Street and Numb~r) /
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to and am and havs b4en e bona fide resident of ths Stats of Florida :inu a day of
/~L~lAA.~ ~
_ , 191~, and I rnide at ~ • ~
(Street and Numb~r)
FORT PIERCE, SAINT LUtIE COUNTY, FLORIDA
and this statement ii to be tsken a: my declsrotion of citizenship, actual layal ~esidencs and domicilo in ths Stat~ of Hotida.
(in:ett here any p~rtin~nt fact:, ~uch as =ale of propeny or busineu, or reli~quishm~nt of ~mpbym~nt
at form~r domicil~„c~mQv~l of f~mily to n~w domicil~, purch~u of horrN, ~tc.)
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1 FURTHER CERTIFY that I will oomply with all other requirementt of a lefla) re:ident of thit Stat~.
1 FURTHER CERTIFY thst I havs no intentio~ to return to my former domic,ils, and 1 int~nd to r~main in FORT
PIEZCE, SAINT IUCIE GOUNTY, FLORIDA, perm~nently.
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. , , , , (Name)
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~ ~ ' ~dfeif~
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~ Swom to s~d~~burfbed befors me thi: -Z day of , i9~
• - V
ROGER POIYRAS
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. _ ~ZL~RK CIRCUIY COURT Notary Public
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By ~.C. My Gommission expires
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(Yo b~ ox~cutod in duplicsta and oripioal fil~d with Clo?k Cirwif Court, •nd dupliut~ with Tax Ass~asota
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