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Declarafi~n ot Domicile antS ~i:izenship
i0 THE STaTE A1~D COUNTY TAX ASSESSOR, 2~~L~~o
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51. IUCIE COUNTY, FtORI~A:
Th~s ~s my declaraLon of Dom~c~le and Citizensh~p in the State of Flor~da that ! am fii~ng this day in accordance and ;
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;n contormity w~th Chapter 222, Sect~on 222.17, Ftotida Stasutes. . ~
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I was fo~meriy a legal resident of 'S ~-vv C 0~] ~ _ t
(Clty) - - ($tat@) a
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3~ C1~ ~ 0 Gv' /t~~ However I have changed my domiGle
and 1 resideti at _ _ ~ t
(Street and Number) ~ ~
ao and am and have been a bona fide resident of the State of Fiorida since day of
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~ - _ - 14~ l , and 1 reside at _ -
- - (Street and Number) ~
FORT PIERCE, SAINT LUCtE COUNTY, FIORlDA
ar,d this statement is so be taken as my dec{aration of citizenship, actuat legal residence and domicite in the State of florida.
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(lnsert nere any pertinent facts, such as sale of property or business, or refinquishment of employment !
at former domicile. removal of family to new domicile, purchase of home, etc.)
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- 1 FUR i HER CER7IFY that 1 will comply with all other requirements of a legal resident of this State.
I FLRtHcR CERTIFY that I have no intention to return to my'former domic,ile, and I intend to remain in FORT
- PIcRCE, SAIN7 LUGE COUNT1l, FIORIDA, permanenNy. ~
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iJ (Name) j8 l I~ V' ~
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Swarrs to and subscribed before me this ~ ciay of • 19 • `
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- ROGEU' POi~~:,; " .
tLESiK G{RCUI~'~~`O~~R'r Notary Pubiic
G~ , i' p,C, My Commission expires
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('[o b~ oxlu+t~d~te? ~up1ltl~fs altd origin~t fited with Glerk Greuit Court, and duplieat• with Tsx Assassor.)
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