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q~cfar:~tivn oi DGmiCi~e and Ci:ir:;n~~:i,~
7hE STA+'E A\D CO:itiTY TAX AS~~~SOK,
S'., lU~:s: COUihTY, F:ORIDA `14184s `
7h,s :i my deciarat;on ot ~a~1~c~~e and C~tizensh,p in tha Sta:e of Fior+ua tt,at f am i;l~ng tn;s day in accorcar:e and
^ con~orm~ry w~th ~hapter 222, Sect~on 222.17. F:or~aa Stat~tes.
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t was iormeriy a legai resident of __~=_Z_~_~ t ~ -
~ C;ty) ~ {State}
,.nd I residea at ~c~_ ` - - - _ However I have cnanged my corniGie
(Street and Nurr.ber)
~o and am and have been a bona fide resicient or the State of fiorida s~nce r~`,~° ~-~J- __11__ _ ciay of
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14-- and I res;de at 1~ L~o _j~`~~' `_/rc~' t C~'
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(Street and ti.;m5er)
+=0R7 PIERCE, SAIN? lUt1E COUNTY, FLORIDA
and th~s statement is to t+e ;aken as my declaration of c;;~ze~sh~p, octuat ;ega~ res~dence ard co^-~.ciie ~n sFe Srace cT "riorida.
(tnsert here any pert~nent facts, s.;c . sa~e of property or bus;ress, or re~ir.c~;;shme~t ot emp;oymen:
: at lormer domiciie, removai of fam~dy to new domicile, purchase of nome, eicJ
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yatab~is$[~n:- resi^e:^c~r in St. Zucie County, Florida
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I FuR7ricR CE2T;rY thai 1 wiii compiy with ai; oit-~er requirer:~e;~;s of a iega! resicent oi r'r+:s Ssate.
; F,;nTn:R CEr2;;"rY that i have r,o inters~crZ to return ro'my iormer do~n~U:e, ond i;n;er.d to remain ~n ;OR7
~.:2C~, SA~ti; ~:;:,iE CO~i;~'Y, FL^vRlDA, pzrmanently. ,
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~ou~? ?a Harinan
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Sworn to ~d~'s~bscr:bed tefore me th~s g`r Cay of ~ b er ; 9~1_.
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RQGER POtTRAS; ~ - -
CL~RK CIRCUj~ COURt 1o:ary P„c,:::
~ ;,y ~~C/ D.C. My Comrn.ss~on ex~;res
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(To be execufed in du,~:icate and original filed wit}~ Uerk C'srcuit Court, and duplic~:e with Tax Assc~~or.j
~ 6GR~ ~~7U F~CE iG~71~
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