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Deciaration of Domicile and Citizenship
TO THE STATE-~iVO~Z6UNTY TAX ASSESSOR, ~SS'14
Sl. lUC1E COUNTY, FIORIDA: ' 1
4
This is my decla~ation of Domicile and Citizenship in the State of Florida that 1 am filing this day in accordante and ~
~n conformity with Chapter 222, Section 222.17, Florida Statute:. ~
~
1 was formerly a legal ~esident of ~ ` -~~Z:~^
(C;ty) (State)
and 1 resided at _.1~: n~~~~_~~~ ' . Nowever 1 have changed my domicile f
(St~eet and Number)
to and am and have been a bona fide ~esident of the State of Florida since day of
~ 7~~' s' I~~
_ , 19_~ r, and I ~eside at
{Street 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 Flo~ida.
(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.)
I~G,~~Ld,
215614
;
ST~~UCIE COUNTII FtA~. .
ROCER P01?RAS
~ • CIERK C~RCUIT COtIRT ~ ~ ~
RfCORD YERIFIEQ..~.~.,~(„L ~
s~ i5 ii 3z aM ~ti
,
,
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1 FURTHER CERTIFY that I will oomply with all other requirements of a leyal resident of this State.
1 FURTHER CERTIFY that 1 have no intention to return to my former domi4le, and I intend to remain in FOR7
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. -
~
(Name)
C~ia.rt/~s I3. F//e~
(Address)
Sworn to and subut~d before me this ~ day of , T9~.
:~,~~~..I N U.: t ~ ,
ROGER P ~~'~?L`.~ J~~ .
CIERK CI1~C~~
y~, T~ Notary Public
,
:
ey ~ z Y„ D.C. My Commission expires ~ ~
~ i C • • ~-~`~s a>a • ` ` ~
. ~ / 1 ~ ~ ~ , ~
; - L • . ~
Ro be ~x~bd'' du +lnd 'ori ~t~al filed with Clerk Grcuit Court, snd du licate with Tax Assossot.) ~ '
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No. 13 A BQOK 195 Fa~r1$34 ~
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