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Declaration ot DomtCil~ and Citizensh:~ . ~
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. 215239 '
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. lUC1E COUNTY, FIORIDA: -
This is my declaration of Domicile and ~itize~ship in the State of Florida that 1 am filing this day in accordants and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
FARNIN6TON 48024 \ MICMIQAN ,
I was formerly a legal resident of
(Ciy) (State)
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and I resided at , 31865 ~ CO RO N E T DR 1 V E . Howeve~ 1 have changed my domiCi~e
(Street and Number) ~
ro and am and have bee~ a bona fide resident of the State of Florida since 1 sT day of i
.
DECEMOER ~ 19 69, and f reside at 2949 $ANTA AN 1 TA~ PT. $T ~.UC I E. FLA. +
(Street a~d 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 Horida.
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-pnserrfiere any periinent facts, such as sale of property or business, or relinquishment of employme~t ' 4
st former domicile, removal of family to new domicile, purchase af hame, etc.)
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JILI RENEE WERNER
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FIlEO AKO REC4R~E~ - . '
St• ROC~R OStRAS~.I ~IJ~
CIERx ~1RC111t C.._y"~ ~ ,
~E~OAD vER1ftECa~'~'~ ' .
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~15239
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I FURTHER CERTIFY that I wil) comply with ell other ~equirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domic.ile, a~d I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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SEYMOUR S ~ WERNER - r
Q:.
~ 2949 SANTA ANl+TA~ PT. ST. LUCIE, FLA•
~ (Address) 33450
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8TH SE~TEMd[R ~1 ~
Svro?rY rtd, subsc~ibed before me this day of , 19 . ,
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, , C~Q ~~C~rt ~ Notary Public
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By ~~R , Bt ~ My Commission expires
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(To ~~,~c irF.duplicat~ and origi~al filed with Clerlc G~cuit Court, and duplicat~ with Tsx Assessor.)
600K NICE ~z ~
No. 13 A ~
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