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Declaratian of ~omicis~ and Citizenship ;~1~556
T~ ~HE STATE AND COUf~TY TAX ASSESSOk, R • ~
Si. LUCIE COUNTY, fLORIDA
Th~s ~s my dec~arahcn ot Dom~cile and Gi~zensh~p in the State of florida that I am filing this day in accordance and
.n conformity with Chapter 222, Section 222.17, Florida St~tutes.
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I was formerly a legal res~dent of __~_~.~"I_~11~_._.______________ _ _-_~c
(City} (State) ~
a nd I ~es~ded at - - ~l - l/. - - _ - _ _ _ _ However I have changed my domicjle
(Street and Number)
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ro and am and have been a bona f~de resident of the State of florida s+nce ~ ~ day of
' L-~ ~ - - 19_7~ , and I reside at ~P ~ tt ~i--
` treet and Number)
5 FORT PIERCE, SAIN? LUUE COUNTY, Fta'7~iiDA
i and th~s statement fs to be taken as my declaration of citizenship, actual legal residence and domicile in the State of F{o~ida.
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~ (Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
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° at former dom~cile, removal of fam~ly to new domicile, purchase of home, etc.) ~
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, I FUR i HER CEK i i'rY that I will compiy with all other requirements of a legal resident of this Siate. i
; I FURTMER CER7IFY that I have no intension to return to my'former domiule, and I intend to remain in FORT
P+cRCE, SAINT lUC1E COUNTY, FLOR{~A, permanently.
KENNETH M. KROME
- - /_~.~.r
i~ . (Name}
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' . ~ I"i" N~i _ y~~"• ~'Gt'~""~ - -
: . ' ' . (Address) ,3jy~--L
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_ Swwn !o and subu~~bed before me th,s day of ~~%L~ e!~`C-.~._ , 19_Ll_. }
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R~GER POITRAS `
- CLERK CtRCU1T COURT Notary Pubiic
= a f
_ y _ D.C. My Corr~mission expires
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(?o be exowtod in duplicate and original filod with Clerk Circuit Court, and duplicate with Tax Assessor.)
= °~R~ 196 F~~.f1600
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