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Declaration of Domicile , and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. IUCIE COUNTY. F~oR~oA: 219401
Th~s ~s my declaration of ~omicile and Citizenship in the State of Florida that I am filing this day in acco~dance and
~n conform~ty with Chapter 222, Scction 222.17, Florida Statutes.
1 was formerly a ieyai ~es~de~t of Hinadale _ _ New Hampahire
(C;ty) (State)
17F Riverview TTSiler P8Y'k . Howeve~ 1 have chan ed m domitile
and 1 resided at _ 9 Y
(Street and Number)
ro and am and have been a bona fide resident of the State of Florida sincs _ 2 ~_st_--_ day of
_Nbvember_ ~q ?1_, and I reside ar _206 Amv Lnne
(Street and Number)
FORT PIERCE, SAIN? LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal ~esidence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of properry or business, or relinquishment of employment
at former domicile, removal of famity to new domicile, purchase of home, etc.)
Place children in public achool.
John I. Hritz ,J~ . 10 yenra ~
F EO Ati~+ RE~qt
Pemela L. Hritz 9 years =~~~+f CouMT~r~
RoafR Po~t+~~a
! RECORD VER~F ED ~~~C~
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~ I FURTNER CERTIFY that I will oomply with all other requirements of a leyal resident of this State.
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~ 1 FURTHER CERTIFY that I have no intention to retum to my former domicjle, and I intend to remain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ (Name)
John I. Hritz, Sr.
_ 206 Amy L ne
(Address)
. ' ~ G'~C 19~.
_ Swpur.tA•qr~-s,~bSctibed before me this day of ~ . ,
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r": • ROGER POJT~AS% - I
; CLERK CIRCUTYj Cb~JRY Notary Public
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Sy ~.C. My Commission expires
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~ (To be executed in duplicste and original filed with Clerk G~cuit Court, and duplicate with Tax Assessor.)
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