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l~~~larat;~n o~t C~~micile an.3 Ci:~zens.i:;~
7HE S7ATE Afv~ COUi`TY TAX AS~E~SOR,
~
5i. L'UCiE COUNTY, flOR1dA:
7n~s ~s my dec~a: ation oi Dom~ci~e and C~t~zensh~p in the 5tate of Flor;cia that i am fi~~ng this day ~n accordance and
n co:~iorm~ty with Chapter 222, ;ect~on 222.17, Florida Statutes.
Stanford Cor.necticut
i was forn.eriy a legal resident of - -
(City} (State)
62 Severence Drive
and I resided at However i have changed my domicjle
(Street and Number)
~'ovember 2
ro and am and have been a bona fide resident of the State of Florida since day of
114 Esst rrima Viate Blvd.
- - - - - - - 19_71_, and i rerde at - -
(Street and tVumber)
FORT PtERCE, SAiN1 LUCIE COUNTY, F10RIDA
and this statement ~s to be taken as my declaration of citizenship, actual legai residence anci domicife in the State of Florida.
(Insert nere any pert;nent facts, s~cn as sale of properry or business, or relinquishment of emp;oyment
~ at forme~ domicile, removal of family to new domicile, purchase of home, etc.)
1
Jodi LoDolce
,
Denni a
; fILEO ~NG RECOROED
~ ~~'~18eI n ST.IUClECOUN~Yf~A.
' ROCER POITRAS
CLERK CIRCUIT COUAT ~
_ RECORO VERIFIEO~'~ ~
~ 3 9 44 ~'l~
218~82
~
_ I FURTtiER CERT~FY that I wi;i comply w+th aU ~ther requ"sremenss of a legal residant of this State.
,:~s
I FuRTHcR CER7iFY that I have no intentio~ to return to'my former domiu:e, and { jntend to :ema~~ in FOR7
~~cRC:, SAltiT L~CtE CUJ~i7Y, FLORIOA, permaner~tfy. .
, - ~ /
~ ~ O ;s-C~~,~ ~ ~ ~
_ _ ; . _ (Name) ~ ~
_ ` ~ ~ ~Y~ C.r'l.t P + i C ~c p
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_ . . + • (r`.~dress}
- .
' - / Svrp~tj~fq aAd subscr~bed 'oefore me :his 3 day of -_~IIYEmhEt_ , 19~1. ;
~ ~ L~ V
= •
- ROGfii POITRAS - -
_ CLFkK CIR~JT COUR7 Notary Pubi~c
.
,
} dY z!_!~
` - D.C. h;y Comm;ssian exp;res . -
,
3
= (To bo Gxowted in duplicato and or+ginal fitQd with Clork Circuif Court, and duplicate with Tax Ass~ssor.)
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