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Declaration ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
Si. IUCIE COUNTY, F~oR~oA: 218~2
This is my declaration of Dom~cile and Citizensh~p in the State of Florida that I am filing this day in accordance and
~n conformity w~th Chapter ?22, Section 222.17, Florida Statutes.
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1 was formerly a legal resident of ~ • I'!LL~2~~`±4~_ _ _ _ _ - -
~ (City) ~ (State)
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and I resided at f`'• ~_~jI_ Howeve~ 1 have changed my domicjle j
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ro and am and have been a bona fide resident of the State of Florida since _ day of {
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_ , 19__~/ and 1 reside at "Q ~
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FORT PIERCE, SAINT LUCIE COUNTY, FLORIOA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florirla.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment ~
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at former domicile, removal of family to new domicile, purchase of home, etc.)
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Fi~EO AKO Rfcoa~EO
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~ Sj.I~CtE "vOUMtY \
~ CLEaR C RC 1 CO pT `
1 RECORO yERIf1E0
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n 1 FURTHER CERTIFY ihat 1 will comply with al~ other requirements of a legal resident of this State. _
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:4 1 FURTHER CERTIFY that 1 have no intention to return to my farmer domiule, and 1 intend to remain in FORT
~ ViERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ ~ . _ _ _ 1 __SCY~~
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_ (Name)
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~ Swom to and subscnbed before me th~s . . day of <
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~OfTRAS
~ . •,.-~K.CiR~W COURT - - Notary -Publi~ - - _ -
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gy . ~ . . : < - ~.C My Comm~ss;on exp~res ~
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lTe b~ ~saMd in ciupiiuts •nd oriqi~al fil~d wit1~ Cl~rlc Circuit Courf, snd dupliuts with Tax As~ssor.)
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