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Declaration ot Domicile and Gitizenship
TO THE STATE AND COUNTY TAX ASSESSOR, 21'7940
5~. lUC1E COUNTY, FLORiDA
Th~s is rny declaration of Domiule and Citizenship in the State of Florida that I am fii~ng ~his day ~n accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of %i~~ • -~z'~t=`~ -
City) ( ate)
and 1 resided at ~JCi ~y ~Zc~.-.~-_~ _ _ However I have changed my domiG~e
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since ~G~'L~ _ day of ~
a /
, 19__ and I reside at ~ .1~ _ ~ r ~ _
(Street and N~mber~
FORT PIERCE, SAIN? LUCIE COUNTY, FLORIDA
s and this staten~ent is to be taken as my declaration of citizenship, actual lega~ residence and domicile in the State of Flarida.
(Insert here any pertinent #acts, such as sale of property or business, or relinquishment of employment
5 at former domicile, removal of famiiy to new domicile, purchase of home, etc_)
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PO YIUS tA. ~ny
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/ `l -e?~t' RECORD YERlFtEO~ ~
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i~~-u.~ ~ - 21'7940
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- I FURTHER CERTIFY that I will comply with all other requiremenis of a legal resident of this State.
= { FURTHER CERTIFY that I have no inte~tion to return to my former domi~le, and 1 intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
_ ^
_ CNARLe7T-E ame~Rm~ SoN
~
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(Address) ~
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~ Sworn~to and subscribed before me this - day of ` f'r' ~"j~-~;~-,-*%GL:_`2 19!1
- . .
. . .
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: ROOER ~OiTRAS
C1FRK GIRCUIf~ COURT j' Notary Public
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By _ `~_~<<~~ ~ D.C. My Commission expires
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_ • • . 6
(To b! ~~cut~d i pliuts and oripinal filsd with Clerk Circuit Co~rt. and dupliute with Tsx Assossor.)
~ , ~ aoox 196 ~~~E 2192
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