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Declaration ot Domicile and Citizenship
TO THE STATE ANO COUNTY TAX ASSE R ~~VV~~
SSO .
Sl. IUCIE COUNTY, FIORIDA:
This is my declara?ion of Dom~ule and Citi2enship in the State of Florida that 1 am filing this day in accordance and
~n conformity with Chapter ~22, Section 222.17, Florida Statutes.
.
I was formerly a legal resident of ~/!L7 ~ e!~ ffQ . e~~~?C~O~l~~ -
(City) ~ (State)
and 1 resided at ~ i_~~ _ r . H wever 1 have han m mi 'le
< 1 r? i? ~ o c g e
d y d o u
(Street and Numbe~)
to and am and have been a bona fide resident of the State of Florida since _ day of
~
- ~i _ , 19_ ~ , and I reside at _ _~~~e. / G ~'r~~~~l/~~
~ (Stree and Number)
FORT PIERCE, SAINT tUG1E ~COUNTY, PLORIDA
and this statement is to ee idKC11 os :ny declaration of citizenship, actual legai residence and do~~.itile in the State of Ftorida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, ett.)
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f t,~EO AND REC Of
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CLERII CI,t~1NT CO~AT ~
RECORD YER~f~EO ~
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~ I FURTHER CERTIFY that I will comply with all other requirements of a(egal resident of this State.
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I FURTHER CERTIFY that I have rto intention to return to my for~ner domicjle, and I intend to remain i~ FORT
j PIERCE, SAINT LUCIE COUNTY, FLORIDA, pe~manenfly.
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? _ ~ (Name) /~'Iyrm/~ ho~os
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~ _ ~o~ _
(Address)
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Swam to and svbscribed 5efore me this _____1 Q___ day of , 19 ~
.d
ROGER POITRAS ~
CLQK CIRCUIT C0ilRT ~ Notary Public
gY - - .C. My Commission expires _
_ .
_ •
Ro bs ~xecated in duplicat~ and oripinsl ~iled with Cl~rlc Grcuit Courf, aed dupliuts witls Tax /~ssossor.)
,3 dooK197 P~~E ~
132
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