HomeMy WebLinkAbout1779 21~669
Deciaration ot Dorr~icile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, 1
51. IUCIE COUNTY, FIORiDA ~
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This ~s my dedaration ot Domicile and Cihzensh~p in the State of Florida that 1 am fil~ng this day in accordance and
:n co~formity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of . v
(C;ty) (State)
and 1 resided at ~ ~ BOX y(~ However I have changed my domiGile ~
(Street and Number? j
1
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ro and am and have been a bona fide resident of ths State of Florida since day of s
c
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; , 19__ % and I reside at ~~'G~' - ~ ~ -
} (Street and Number)
Y
FORT PIERCE, SAINT tUCIE COUNTY, FLORIDA
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K and this statement is to be taken as my declaration of citizenship, actual legal resicience and domicile in the State of Florida.
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Y
~ (Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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fILEO AND RECp~ OEp
~ti. LUCIE COUMTY F~L
IlBCER POITRAf
`y CtERK CIRCYIT C
RECORO ~ERIFIEO
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21~ I 4~ 'TI
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- I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY ihat I have no intent+on to return to my former domiule. and I intend to remain in FORT
'r~
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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_ (Name)~EE ~
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` ~ _ _ _ _ _ _ .~1'_1 S~ .
~ (Address)
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~ Sworn to and;ubscr~bed before me th~s _ da of _ '
Y - - - 19~__. :
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~ ? ~ . ~ ~ •
~ . ICDGER i~+pITRAS ~
= CL~AK ~ T COURT Notary Public
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BY - ~ - ~ - D.C. My Commission expires
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(To bs executed in duplicate and oriainal filed with Cl~rk Circuit Cov~t, and dupliuts with Tax Assessor.) ~
: „ BOGK 196 Pa~E 1778
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