HomeMy WebLinkAbout1434 _ _ _ _ ._a s
_ - _
_ _ _ _ _ _
- .r
Deciaration ot Domicile and Citize~rship
~ O THE STATE AND COUNTY TAX ASSESSOR,
~l. LUCIE COUNTY, FLORI~A:
Th~s ~s my deciarat~on of D.;~~~~c;;e ar.d Citize~ship in the State of flonda that 1 am fil~ng this day in accordance and
~n conformity with Chapter 22~, Section 222.17, Florida Statutes.
7 '
~
I was formeriy e legal resident of ._.2~-,~~L~' ' ~1L1f~' _ ~`r ' , _ _
~ (City) (State)
~ /
and 1 resi~ed at e,- ?~!1~ __~~e-~'E ~ ~~~'-~t~ -Cf~owever 1 have changed my domicjie
~
(Street a ~ Numt~r)
to and am and have been a bona fide resident of the State of Florida si n/ce _ r_~_~ day of
~ a~c~"`~M~ t7[C2cC~ ~~l~cl~
_ _ C! ~~t ~ ~!~7~ ~~-E= "Z~-- , 19~1-, a~ ! .as ~de at ~a~-~ ca' , _ _ ~
~~e , ~ o
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actuaf legal reside~ce and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at fo~mer domicile, removal of family to new domicile, purchase of home, etc.)
I •
~ '
~ ~---j ~ yh ~
~L -4.~ ~
i ~
~ , ~
~ J-c~ d~ 1~ z~ f 4~0 ~~,a Re a e
3 ~oceR~~o
~~j~A, y ~
3 y
~ RiCORD VfR it`~o 4°~f
:
,
~ No~ 76 ~ PM'TI
~
F
7
J
4
e
~ I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
~
> I FURTHER CERTIFY ihat I have no intention to retum to my former domitiie, and I intend to rerrain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently.
_ ~ ~
~a Y ~ 4- ~
_
(Name)
_ c~ ..:Np'e
~ (Address)
, ~ ~ '
_ ,v, C: i~ `'~5~;
,
9t~1~~ C, _ ~j~ n~ nt. /u~ -
~ . ` ~ ~
~ ~ ~~v~' t t~d~~ui~sCribed before me this day of 19~~
: < s; Ic` Q _
~'z : i, RQ ~'~AS /
- : , i
= $ ">,:G~ - "~C+1'R
f,VI~~ COURT ~ Notary Public
`-3 ey ~ O L~~~v/ D.C. My Commission expires
- ~ ~
• .
_ ~ (To be executed in duplicate and original filed with Clerk Circuit Court, aod dupliute w+th Tax Assessor.)
b00K P~E~~~