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De~laration ot Domicile and Citisenship ~s'20~
TO THE S1ATE AND COUNTY TAX ASSESSOR, ~
51. lUC1E COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and
~n conformity with Chapter 222, Sectio~ 222.17, Florida Statutes.
I was formerly a legal resident of . J7 `s0_ud~~ ~ f ~~1L~~
(City) ~ (State)
t
f
and I ~esided at J`~ L.~ o. X_ ~l 9~ - . However 1 have changed my dorniCile
(Street and Number) ~
to and am and have been a bona fide resident of the State of Fiorida since 1~_ ~~,7~~___- day of
, 19 2.l , and I reside at l
a~ ~e~~~~'-~
(Street and Number)
FORT PIERCE, SAIN? 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 sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
1
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C' ~1 ~ r 1~e 5 7" ~t eo d u~r e. ~r ~9 t To r~~c S.LZ ~
~15203 ~ ~
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- EILEO aNt+ REC~a~EO
St. LUCtE COUNTY lA-
a~~rz pplTftJ?S
CIERK Ct ~ CUtT COURT `
~ aECOa~ v~a.F~EO
~ 1 ~ 59 PM'1 ~
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~ I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that 1 have no intention to return to my former domiGte, and I intend to ~emain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permaner~tly.
-
. (Name)
~ Di eber
~ - .
~ ~ ~ C~t
~ (Address)
~
~ : ,s
~ . ry
~ Sworn to and subscribed before me this _ _ _ day o . , 19_L__~.
~ ROGER POITRAS
~RCU~,Y,~COUR~ Notary Public
.
BY - _ _ - D.C. My Commission expires
- (To b~ ~x~cut~d in duplicat~ and oripinal fil~d witi~ Cl~rk C_7. rcuh Court, and dupllute wlth Tax Ass~ssor.) ~
„ do~ ~95 ~?~si52
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