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Declaration o! Domicile and Citizenship
21S165
TO THE STATE AND CQUNTY TAX ASSESSOR, ~
Sl. IUCIE COUNTY, FLORIDA:
This is my decla~ation of Oomicile and Citize~ship in the State of Florida that I am filing this day in accordance and
~n conformiry with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of O ! _ - . L~ - _ _ . - - - - -
~~~/r~ (City) ~State)
and I resided at _ ~ v ' _ _ _ _ _ However I have changed my domic~le
(St~eet and Number)
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to and am and have been a bona fide resident of the State of Florida since y '
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- _ I _ _ _ , 19_7l , and I reside at - 3 - . _ . '
treet and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
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 sate of property or business, or relinquishme~t of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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F~~Ep ~?MD RECORDEO j
ST. LUCIE COUNTY F~A. ` ~
pOGER PO~TRAS ~
CORO VER F EO COURt
RE
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1 FURTHER CERTIFY that I 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 domi~ile, and I intend to remain in FORT
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PIERCE, SAINT IUCIE COUNTY, FLORIDA, permanently.
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~ j' ~~S~prqi~~fp'o~ subscribed before me this _ day of - ~~7~ , 19~.
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" ' ~ COURT Notary Public
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By , D.C. My Commission expi~es
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(To b~ execut~d in dupliut~ and original ~il~d with Cl~rlc G~cuit Courf, and duplicsh with Tax Ass~sior.)
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