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Oeclaratio~ ot Domicile and Citisenship
TO THE STATE ANO COUNTY TAX ASSESSOR, • ~58~
Sl. IUCiE COUNTY, FLORI~A:
This is my declaration of Domicile and Citizenship i~ the Stete of Florida that 1 am filing this day in eccordance and
~n conformity with Chapter 222, Section 2Z2.17, Florida Statutes.
1 was former! a ! _ ~od~ric]c '
Y ~9a! resident of r - - - - _ Ya~18II(1
(Ciry) (State)
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and I resided at _ 1492 Reat lO_etrea~ _ _ . However I have changed my domitile
` (Street and Number)
to and am and have been a bona fide resident of the State of Florida since _ _ 2~d_ _ day of
_SoptQmber i9___?land I~es~de ar .__?$~.2_._ 1111tahire T~rraco
(Street and Number) ~ ~
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FORT PIERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residente and domicite in the State of Florida. ~
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(Insert here any pertinent facts, such as sale of property or business, or reiinquishment of employment ~
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at former domicile, removal of family to new domicile, purchase of home, etc.) ~
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Fstabliehing reaid~nae
Will movo iato thier new ho~e is approzimately 30 da~a
1430 San Ignacio ZaYe ~58~
F LEO Att~ RECOR~EO
S~.IUCtE COUMTY ~A.
ROCf ft POITRAS
CIERK CIRCUIT COURT
RECORO YERIPtEO~..~~
` SEP 1~ 2 23 PM' I
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I FURTHER CERTIFY that I wil) comply with al) other requiremsnts of a teyai resident of this State.
1 FURTHER CERTIFY that I have no intention to return to m~ former domic,ile, and I intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, fLORlDA, permanently.
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, ~ ~ - . `G . ~ ~~(Name)
~ T ome?e Z n,~do =
" . ' ~ ~:.c._.,%
- ~ ~ ~ Ruth ~E~d or ~
. ay .
Sworn~to and subscribed before me this _ 20th day of ~SaPtvmber 19 'jl ~
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RO~iER POITRAS ~ _
K CIRCUiT COURT Notary Public
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BY a~~ D.C. My Commission expires
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i (TO ~f! ~XKYMf~ in dupliu» and oriQinal ~il~d witb Cf~rlc Grwit Couh, and duplieat~ with Tax Ass~.)
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