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Declaration ot Domtcite and Citize~ship `
• TO THE STATE ANO COUNTY TAX ASSESSOR, ' ~~S`n~
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Si, IUCIE COUNTY, FIORIDA:
This is my declaration of Domicile and Citizenship in the State of Flo~id~ that I em filinp thit day in ~coordanu and
in conformity with Chapte~ 222, Section 222.17, Florida Statutes.
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1 was formerly a leyal re:ident of, ~~~uQ~
- (City) . (51at~)
snd 1 ~esided at ~6 G/.~..t-cQ- . Hovwvef 1 have charp~d my domivle'
(Street a~d Number)
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to and am a~d have b4en a bona fide re:ident of the State of florida :i~u 1" f day of
J~~~~~ , 19~, and I reside at~
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r~~ • LL~.C"~'~-~ ~~~`~er~s'<<--~~~
'~J 1"~1~1
~ (Street a~d Number)
FORT PIERCE, SAINT LUCIE COUN?Y, FLORIDA
and thi: statement is to be taken as my declaration of citizenship, actual legel residenca and domicile in the St~t~ of Hotida.
(Insart here any peninent fads, such as ssle of property or busines:, or relinquishm~nt of employm~nt
at form~r domicile, ~~moval of f~mily to n~w domicil~; purchase of hom~, ~tc.) •
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F~z:a ~tMB RfCO E ~
si ~uc~f cow~n~~,
~ c~ER°~~c ncu~~c~oSwtt
_ RECORD 1?ERIFIEO _
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1 FURTHER CERTIFY that I will oompty with all other requiremants of a le~al resident of this Stste.
I FURTHER CERTIFY that I have no intentior~ to rsturn to my fwmer domicjle, and 1 i~tend to ~emain in fORT
PiERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ Swarn td and~ ~•'~c~ibed before me thi: day of ~ti- 19~.
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- <AQ6~R ,POITR%~'S''
~ I~~~OURY Notary Public
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By D.C. My Commis:io~ expi~es
Ro b~ ox~wt~d in duplicab and oripina! filad with Gl~rk Grcuit Court, and dup~iut~ with Tax Asa~ssota ;
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~~i95 ~ 9~?
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