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Dcclaration Domicile and Citizen~hip
~ O 7NE STATE AND COUNTY TAX ASSESSOR, 21~•yCpO ~
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Si. lUC1E COUNTY, FIORIDA: ~
Th~s ~s my deciarahon of Donuci~e and Gtizenship in ti~e State of Floricia that I am filing this day in actordance and
~n conform~ty w~th Chapter 222, Section 222.17, Florida Statutes.
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I was formerfy a iegal resident of _ ~
(City) (Sta
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and 1 resided at _ _ ~3'~5.~ _ _ ~ _ _ However I have changed my domicjle
~ (Str et and Number) :
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so and am and have been a bona fide resident of the State of Florida since _~_Q day of
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` - _ 19~f., and I reside at ~ ~ ~
~ (Street and Number)
~ FORT PIERCE, SAINT WCiE COUNTY, FiG:..:.A
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: and this statement is to be taken as my declaration of citizenship, actual legai residence and domicile in the State of Florida.
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~ (Insert here eny pertinent facts, such as sale of pro~erty or business, or relinquishment of emp;oyment
' at former domicile, ~emoval of family to new domicile, purchase of home, etc.)
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~ Oct ~0 ~ ~M'11
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21'7580
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- I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State. i
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i FuRTHER CERTIFY tnat I have no intention to retum to my 'former domic?le, and I intend to remain in FORT '
?:ERCE, SAfNT IUCIE COUNTY, FLORIDA, permanently.
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_ Name) ~e e / ~ y
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- (Address)
_ ,.Swor~ to and subscribed before me this - ~ day of ab~
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. R TRAS ~
_ " ~ R~llt'i COURT Notary Public
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~ Gy ~ D.C. My Commission expires ~
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(To be executod in duplicate and original fiied with Clork Circuit Courf, aod duplicate wifh Tax Assessor.)
_ eoo~ PACE1644
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