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Dectarat:~n of Dor~icile an~! Citizens~ip
21'7~23
TO THE STATE AND CGUNTY TAX A~SESSOR, •
51. IUCIE COUNTY, FLORI~A:
ih~s ~s my declarat~on of Dcmiuie and Cit~zensh~p in the State of Florida that I am fifing this day in accordance and
.n conformity w~th Chapter 222, Sect~on 222.17, Fiorida Statutes.
1 was formerly a legat resident of ____~8~_ u8.'G~_~Q~.___-__ _ '~.88S8C~.U8=`tts {
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(C;ty) (State)
and 1 resided at 1~_~YE~t_~yr~E~-~------- However I havechanged my domiule
(Street and Number)
` ~o and am and have been a bona fide residenr of the State of Florida since ___~Q_t4~4L___~~~lday of
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~ _ _ _ 19~ _ , and I reside at __~~23 ~adger COLiTt
~ (Street and Number)
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FORT PIERCE, SAIN? tUCIE COUNTY, FLORIDA
~ ar,d this statement is to be taKen as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
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(Insert here any pertinent facts, such as sale of property or business, or retinquishment of employment
= at former domicile, removal of fam~ly to new domicile, purchase of home, etcJ
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To estab~ ~'h res~derc~ p~we aE ~
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I FURTHER CERTIFY that I will comply with all oiher requ~rements of a legal resident of this State.
I FURTH~R CER~FY~ihat 1 have no intention to retum to my'former domiule, and I intend to remain in FORT
a:c~2CE, SAINT LUGIE~CO~i~~l(,'~LORIDA, permanently. GECR'E K. wEI~HAAS ~
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_ ' ; ~ (Name) `
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~ _ r Rox ~8, RadE;er Court, F'~rt Pierce, F1a ~
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Sworn to and subscribed sef~me this ~ day of ~~tober ~ ~9 71
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ROGER POITRAS ~
CLERK CIRGUIT COURT Notary Public
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f~ t t ~ ~ !t. c . . ~ D.C. My Commission exp~res
= (To be executed in dupficate and origina) filed with Cler{c Circuit Court, and dupl+cat• with Tax AssQSSOr.)
; P ~RK 1~6 ~A~f1390
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