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~eclaratlon of Domfcile and Citis~nship ;
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216201
TO THE STATE AND COUNTY TAX ASSESSOR, ~
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Sl. IUCIE COUNTY, FIORIDA: ~
This is my decla~ation of ~omicile and Citizanship in the State oF Florida that 1 am filinq this day in saordance and
in confo~mity with Chapter ?22, Section 222.17, Florida Stetutes.
1 was formerly a legal ~esident of '~~L~.BZ...QQ111~~_.------- 4t
- (Ciry) (State)
and I resided at _ 4.~'~ 1~gQ]1Zfl_~~ti~-- - However 1 have cfianged my domiGle
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since _.26tk day of
iPril 19-T1 and 1~es~de a~ 765 Jltura Stre~t ~
(Street snd Number) `
FORT MERCE, SAINT LUCIE COUNTY, RORIDA
and this stateme~t is to bc taken as my declaration of citizenship, actual legal ~esidence and domicile in the Stab of Florida.
(Insert here any pertinent fads, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
E~tnbliehing reeidenco ~s~1
s~~i
uci~ co~~~i~~~.
AocER Po~T~~~
CLERK CtACUIY 0011111
IIECORO YERIi1E0~.w•
S~ 28 1 ~t PM'11
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I FURTHER CERTIFY thst 1 will comply with all other requlrem~nri of a lega) resident of this State.
1 FURTHER CERTIFY that I have no intention to retum to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT IUCIE COUNTY, FLORIOA, permanently.
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Sworn to and subxribed before me thi: 28th day of s~ptieIIbe= ~ ~q ?1
ROGER ~OITR/lS _ -
CIRCUIT COURT Notery Public
By D.C. My Commission ~xpiret
(Te M~x~cu~d in duplicat~ ~nd ori~inal Al~d vviN~ ClMrlc Ckc~if Ca+~f, and d~plJuN wiN~ T~x A~~a
d~ 1y5 ~«2fi90
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