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Declaration ot Dor~icile and Cit~zenship
i0 THE STATE AND C~UNTY TAX ASSEJSOR.
51 LUCIE COJNTY, FLORIDA 218~10 !
Th~s ~s niy declarat~on of Dom~nfe and Cit~zensh~p in the State of Flonda that I am f~l~ng thfs day in accordance and
n conformity w~th Chapter Section ?22.17, Fiorida Statutes
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I was fonr;eriy a lega! res~dent of ,~'Jl.~.~Co.,,~. l/~ _
tCity) (Stat
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and I res:ded at / N-~. f~ However I have changed my domi~ile
(Street and Number}
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!o and arn and have been a bona fide resident of the State of florida since Ci~ ~ day of
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; ~ f , 19 /l , and 1 reside at J~ 0 • ~ U ~ __~N`(
' (Street and Number) ~
' FORT PIERCE, SAINT IUCIE COUNTY, FLORIDA
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; .~nd this statemen~ is to be taken as niy declaration of citizenship, actual legal residence and domicile in the State of Florida.
_ (tnsert here any pert~nent facts, such as sale of property or business, or relinquishment of employment
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z at former domicile, ren~oval of family to new domicile, purchase of home, etc.)
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I O-~' AMO AECO~
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` :~_lUC1E CQUNi
~ ROGEA POtTRAS
COa YERIF EO COU~•+~ a`~,
- aE ~ 49 PM' 11
µo~ 5
2I~ ~10
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I FURTliER CERTIFY that I will comply with all other requi~ements of a legal resident of this Stote.
~ I FURTHER CERTIFY that I have no intention to return to my former domi~ile, an~ I infend to remain in FORT
- ?iERC~, SAINT LUCIE COUNTY, FLORIDA, permanently.
'~Y'~'to - ~_4~~?-„1 -~1'l a,~, -~)~~u~--~
(Name)
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(Addressl
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Swoinlo,and subscnbed berore me this _ day of _ l:'~ ' ` ' , 19_~~~
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' ROG~' t0~'~R~ - - -
- CLt~RK CiRCU1T COURT Notary Pub!ic - _ . - - - - - -
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By - f _ t.,~`- . _ _ - - D.C. My ~ommission expires - - -
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(To b1t Oxecuted in duplicate and origina) filed with Clerk Circuit Court, and duplicats wifh Tsx Assessor.)
- ,3 ~'~',1~~ -~~:2703 -
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