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Deciaration o! Domicile and Citizensh~p
• TO THE STATE AND ~OUNTY TAX ASSESSOR, '
S1, lUC1E COUNTY, fIORI~A: ~~O
This ~s my decla~ation of Oomicils a~d Citizenship in the Stat~ of Florida that 1 am fili~p thi• day in acoordana and
in oon(ormity with Chapter ~24, Section 22Z.17. Florid~ Statut~.
1 wa: form~~ly a Ipal rfiKJMt Of gt . 1,oni a ' ~ v.. _
~ ' KIt~/) (St~1r)
and 1 resided at Cope Bri llieutt How~vK 1 hav~ charqed ~I domitjl~'
(Street and Number)
to and am a~d have b~an a bona fide re:ident of tha State of Florida sino~ A day of
, 19~_, and I nside at -
(Str~t and Numb~r)
~ORT PIERCE, SAINT LUCIE COUN?Y, FLORIDA
•nd this statement is to be taken a: my daclaration of citizenship, actual leqal re:idence and domicii~ in tM Stat~ of Hotida.
. (Insert here any peninent facn, such as s~le of property or bu:ine:s, or ~elinquithn~t of
~t formsr domicil~. nmoval of family to n~w domici{~, purchasr of hamt. ~I .
Placing child in achool - Saudra Ann Fair
F 1.E0 ~NO 4tECOftQEO'
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OC~R P01'fRA ~~T l
R ~~aCUtt CO
C~ER ~ERIf IEO
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1 FURTHER CERTIFY that 1 will oomply with •II othst r~quir~msnn of a le~al raids~t of this St~t~.
~ 1 FURTHER CERTIFY that I have no intentio~ to return to my formtr domitile, and 1 int~r~d to r~main in fORT
~ PIERCE, SAINT WCIE COUNTY, FLORIDA, perman~ntly. ~
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_ ' Gs%rn.e.~ atc:t~
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- . . : ' ~ (N+^"°) ~i 11 i e Ja~e s Fai r
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~ Sworn~ ro.ifil ~u6su~bed befor~ ms tFi
i 23 ~y of September , 19
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~ RQGEit POITRAS
CtERK~ CtiCCUR COURT Notary Public ;
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By ~.C. My Gommis:an expi~~: ~
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(Yo b~ ~x~c~t~d ie duplicat~ and oripina! fil~d with Cl~rk Circuit Co~~, ~nd drplkat~ wita Tatt /1ss~ssor3 !
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