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Declaration ot Domicile a~d Citise~ship
TO TNE STATE AND COUNTY TAX ASSESSOR, ~~W
Sl. IUCIE CQUNTY, FIORIDA:
This is my declaration of Oom~cile and Citizenship i~~ the State of Florida that 1 am filing this day in accordance and
~n co~formity with Chapter ?2?, Section 222.17, Florida Statutes.
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I wes formerly a legal resident of lQ_ UYG~ 'r+'u_- ~
(C;ty) (State)
n . n ~ ~ •
and 1 resided at . Noweve~ I have changed my domiCile
(St~eet a~d Numbe~)
to and am and have been a bona fide resident of the State of Florida since .!if~GP, L_~ ! l_ day of
, 19~l, and I reside at -
Street a~d Nu r)
e?/~2 S ~~t-~-~' (/L o
FORT PIERCE. SAINT tUC1E COUNTY, RORIDA
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 ~elinquishment of employme~t
at former domicile, removal of family to new domicile, purchase of home, etc.)
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FI~EO AND REC~R~E~
, S?.IUCiE COUti LA.
ROCER P417R~S ~
CIERK CtRCU1T COURT
RECORD YEA~F~EO
I
~ ~ i~ 9 s2 ~N'71
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~ - 2~15556
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I FURTHER CERTIFY that I will rnmply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domic.ile, and I intend to remain in FORT
PIERCE, SAINT IUCIE COUNTY, FLQRIDA, permanently.
~~~~~e~~~--lt~_./~~ -
(Name) ~ ~
Amb~cS wm- lye~s
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(Address)
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~ ~ ~Vqp~?t~ ibed before me this ____J! "l day of _ , 19~
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• . - - - - - -
-~CL~K C ~'OtJRT Notary Public '
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B~r - O.C_ My Commission expires ~
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Re b~ ~x~cvhd in dupliut~ and ori~ind ~il~d with Cl~rlc Grcuit Cou~f, and duplic~t~ with Tax Ass~ssw.)
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