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Declaration o! Domicile and Citizenship
~ O tHE STATE AND COiiNTY TAX ASSESSOR, • ~ 216619
LUCIE COUNI'Y, FLORIOA:
Th~s is my deciarat~on of Oom~ciie and Citizenship in the State of Florida that I am filin9 this day in sctor~ance and
~n conform~ty with Chapter 222, Section 222.17, Ftorida Statutes.
I was formerly a legal resident of --1=LI~~_ • / ~
(Cfry) (St~t~)
and 1 resided at ~~Q~ ~v~~=~~--' .-S . However 1 have chanfled my domi~ile'
(St~eet and Number) '
~o and am and have been a bona fide resident of the Siate of Florida since ~G~'~ day of ~
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_ . , 19~, and I ~eside at ~ '
(Street and Number) ~/o?~.~' a,
; FOR? PIERCF, SAIN? LUCIE COUNTY, flOR1DA ~
and tn~s statement is to be taken as my declaration of citizenship, actual legal ~esidence and domicile in the State of Horida.
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(Insert here any pertinent fads, such as sale of property or business, or relinquishment of employment
~ at former domicile, ~emoval of family to new domicile, purchase of home, etc.)
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_ F?LEG aH~ RECOROEO
~ ~ ST. LUC1E COUNTY flA.
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a CtEF.~ ;,~tCU1T COURT (
- RFCO~D Vf~.IFIEO~
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y - ~ 216619
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- i FURTHER CERYIFY that I will comply with all other requirements of a leflal resident of this Stete. ~
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~ 1 FIiRTHER CERTIFY that I have no intention to return to my former domitile, and I intetxl to remain in FOR7
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_ ?~ERCE, SAlN7 IUGE COUNTY, FLORIDA, permanently. i
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Sworn tO~and subscr~bed before me thi: day of (t~~ , 19~ ~
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ROGER POl1'RpS
CIERK CtR~ViT COURT / Notary Publit
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; Csy ~ , ~ ~ ~ .C. My Commission oxpiros
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(To be ~xecutod i~ duplicato and oriain~l filod wilh Clork Circuit Court, •nd aupliut• wilh Y~x AsNSCOra
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