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De~ctaration ot Domicile and Citizenship
i0 THE STATE AND COUNTY TAX ASSESSOR, 2195yo
Sl. IUCIE COUNTY, FIORiIUA~
This ~s my declaration of Dom~ule and Citizenship in the St~te of Florida that I am fil~ng this day in accordance and
conformity with Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a legal resident of ___.~pp~~~~~___-_- - 5.~.
(City) (State)
and I resided at 150 _phyllis_ 01 However I have changed my domiC~le
(St~eet and Number)
ro and am and have been a bona fide resident of the State of Florida since October _ 1_ day of
19_71__, and I ~eside at 607 N~. 16th Street
(Street and Number;
FORT PIERCE, SAIN? LUCIE COUNTY, FLORlDA
and this statement is to be taken as my declaration of citizenship, actual legat 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.)
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~lelody Jackson
Ricky Jackson
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~ 1 FURTHER CERTIFY that I wil) comply with all 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 former domiule, and I iniend to remain in FORT
~4 P~ERCE, SAINT LUGE COUNTY, FLORIDA, pe~manently.
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X 'Y
" (Name) etty 3dcIntyre
(Address)
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29th November ~ ~q ?1
~ Sworn to a nbed before me this day of •
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, Rp~' S,. .
.Q~K':~1R ~D~JR1Q Notary Public
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r=:= 8y f r 0.C. My i.ommission expires
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=~-f ~ (To be exeeWed. ~n~~eluplleate and original filed with Clerk ~i~eu' urt, and duplieats with Tax Assessor.) '
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