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Declaration ot Domicile and Citizenship
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TO THE STATE AND COUNTY TAX ASSESSOR, ~~c~~~
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51. IUCIE COUNTY, FIORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that 1 am fiting this day in acco~dance and
~n confor+nity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of ..~J ~-7_- ---.~~¢~it~~-
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(Cify) (State)
a~d 1 resided at ~4, . However 1 have changed my domiCile
(Street and Number)
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to and am and have been a bona fide resident of the State of Florida since ~ _ .Z._~ _.Z~_ _ day of ~
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~~Z.~~~ ~ _ _ TQ - 19~_l_ and 1 reside at ~l ~ -Z----9~5~ 1 @.~~~- '
(Street and Number) ~
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FORT PIERCE, SAINT LUGIE COUNTY, FLORIDA '
and this statement is to be taken as my declaration of citizenship, actual lega) residence and domicile in the State of florida.
(Insert here any pertinent facts, such as sale of property or business, or reiinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
Y-~ ~ / ~ °
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a// ~t,~~ I~ FlIED ANO RfCOR~
G~y "4 ST.IUCtE ~OWttYFL~ ~
, ~ CLERK C HCiIIT COMT
.~L,~~~ ~ RECORD YERIitEO
` SEP 17 3 38 ~
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~ 216121
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1 FURTHER CERTIFY thaf 1 will comply with all other requi~ements of a leyal resident of this State.
~ I FURTHER CERTIFY that I have no intention to return to my former domiGle, and I infend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ (Name) ~
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~ .3.~ d ? - _ -
(Address)
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~ ~~Sworn~to'u~d~subscribed before me this day of , 19~
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~ ROGE~, ~ .~OI~AS _
~ Ct~ERK CJ1~,CUlT OURT Notary Public
~ By D.C. My Cammission expires
(Te b~ ~x~cu/sd in dupliut~ and ori~inal fil~d with ~irfc Grcuit Cou~f, and dvpiiut~ with Tax Ass~s~or.)
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~ eooK1~ PA~E2J83
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