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Declaration ot Domiclle and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, 21~31
Sl. lUC1E COUNTY, FIORI~A
This is my declaration of Dom~ate and Citizenship i~ the State of Florida that I am filing this day in accordance and
~n conformity with Chapter ?22, Section 222.17, Florida Statutes.
I was formerly a legal resident of ~k1ahOIDfl _C~t~/ __01{lahOna______ _
(City) (State)
and I resided at Gen. 'i@Z~VeTy B@th8ri3/ However I have changed my domic,ile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since l~th day of
. j~'ovea~ber , 19_ T1 and 1 reside at . D1X1~_ ~_Q~11~ nome PArk _
3221 ~S0. Dixtie~ ~ighw
FORT PIERCE, SAINT LUCIE COUNTV, FLORIDA For t F i e~• C e~ Fl a.
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(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, etc.)
ftLEO AN~ ltE~pADEO
ST. LUC~k CQU!?Y fl~.
ROCER f01TRAS
CLERK CtRCtlIT C01{RTy~
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Shirley Geil ?~rown RECOqD rER+FIED.~C:
No~r I 9 I! zs 1M'T t
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~ 219131
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I FURTHER CERTIFY that I will comply with ell other requirements of a legal resident of this State.
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' I FURTHER CERTIFY that I have no intention to return to my fo~mer domiule, and I intend to remain in FORT
PtERCE, SAINT IUCIE COUNTY, FLORIDA, permanently.
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~ (Name) ~eI @II BT'OfvTi t
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_ - ~Ad~+ress) - - - ~
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~ Swort~ iu ea~3 suburibed before me this _l _.1 - day of _~7 ~"?'~???~L , 19~ `
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- ROGER POITRAS ' - - - - -
- CLERK CIRCUIT CQ~i~T Notary Public
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BY . D.C My Commission expires ~
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_ (To b~ executed in duplicat~ and ori~in~l filed with Cl~rk Ci~cuit Cowrf, and dupliut~ with Tax Ass~ssor.)
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BOOK PACE
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