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D~cl~~ a~ion ot ~omici~e a~;:! t:i:i::e:n~::s;~
jO 7HE JTATE AN~ COUNTY iAX ASSESJOR, ~ 218Jr~6
~l. II:CIE COUNTY, FLORlpA:
Th~s ~s my d~C;aration of Dom:ufe and C~t~zer.sh;p ~n the Jt~te of Flo~ida that + am fii~r.g th~s day in accordance and
:n conform~ty w~th Chaptzr 222, Section 222.17, Florida Statutes.
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I was formeriy a legal r~s~dent of __.~~iL~?~L~-----_-
(City) !j (State)
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~nd I resided at ~ ,~~~f :'iLLt~ll! ~ : ~ _ However I nave chanc~ed my domiu~e
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(Street and Number)
ro and am and have been a bona fide resident of the State of Fiorida s+nce '_!__s-~_ day of
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_ _ _ _ 19_: _ , and I reside at ~ ~ _
(Street and Nur,:c.. i
; FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and ihis statem~ent is to be taken as my declaration of citizenship, actual tegal r~s:dence and domicife in the State of Florida.
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_ (Insert here any pertinent facts, such as sale of properiy or business, or relinquishment of employment
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~ at former domicile, removal of family to new domicite, purchase of home, etc.)
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~ ~'-C~ ~.Er~ " t f.!_.<tC~~rL~ :~j~. .~`~:7~u. lt:~'
~ ~ / FILE~ Ati0 R~CO~~ED
_ ~ - ~ ~ SL ~uCrE COUNTr
. < < ROCfR POItRAi
~ ~ j- ClERK CiACWT COURT C
_ RECQRD YERIFIEO.~C ~
N~++ 1 IZ ie PH'll
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- 1 FURTHER CERT{FY that 1 wil! comply with ail oiher reguirements of a lega~ resident of this State.
°~-y i FuRTHER CtRTJFY that I have no infent~on to return to 'my fosmer domic~ie, and I intQnd to remain in FOR7
?icRCE, SA~N7 LUCIE COI;NTY, FlORIOA, permanentiy.
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_ Sworn ta and subscribed before me th~s oay of 'j~' <<_' 2». b~' r-- , 19~.
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ROGER PO~TRAS
C~3tCUIT COURT / No;ary ~,;b~ic - - -
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~ ~ ~ ~ D.C. My Commiss~on ex~:;es -
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- (To be executed in duplicate and original filed with Clork Circuit Court, and dupticate with i ax Assossor.j '
- ~co~ 196 PAGf
. 2354
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