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Declaration ot Domiciie and Citizen~hip J
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TO THE STATE ANO COUNTY TAX ASSESSOR,
~l, IUCIE COUNTY, FIORI~A: ~i51'75 .
This is my declaration of Oomicile and Citizenship in the State of F~~.•~da that I am filing this day in accordance and
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~n confo~mity with Chapte~ 22~, Saction 222.17, Florida Statutes. !
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I was forme~ly a tega! resident of _ ~"}h~~_ _ _ _ ~'O~ _
(City) _ (State)
and 1 ~esided at J O`l Yl.e..~., T'o ri r: R d However I have changed my domicjle
, (Street and Number)
to and am and have been a bona fide resident of the State of Florida since _ day of
_ _ _ , 19~L, and I reside at 4a ~ ~ ~ ,
(Street and Number)
FORT PIERCE, SAIN? LUCIE COUNTY, f10RIDA ~ ;
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and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(Inse~t here any periinent 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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13obb,~ A~Y•~a,~...
FILEO A!iD RECOR~£D
S,T..I.UC{C COUNTX ~1A.
4ftOGER ?OITAo~ `
/ ~ftECQRO MERtF~?D.~~ ~
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~ 1 FURTf~ER CERTIFY that I will comply with all other requirements of a leflal resident~ of this State. i
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I FURTHER CERTIFY that I have no intention to return to my former domiCile, and I intend to remain in FORT ;
?iERCE, SAINT LUCIE COUNN, fIORI~A, permanently.
y~,~. ~-d .T• t~~.~.~.~ ~
.r (Name)~ v N C ~4 N
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r Sworn to and substribed befo~e me this day of , 19
~ J~Q .G~R:p4ffiR%?i _
_ ~LERK Cftt~l~l' COURT Notary Public
G~ ~ ~ D.C. My ~ommission expiros
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'4~o-b~~jkf(~~d~in duplicat~ and origiAal fil~d with Cl~rk Grtuit CouA, and duplicat• with Yax Ass~s~r.)
. SooK195 P~~111~.
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