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Declaration ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl . WCIE COUNTY, FIORIDA (
This is my dec~o~ ot~on of Dom~ule and Citizenship in the State of Florida that I am fiiing this day in accordance and
~n conformity with Chapte~ 222, Section 222.17, Florida Statutes. •
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1 was fo~merly a legal resident of ~~~~2~4.~~ ~ --1~''s-~-~ -
(C;ty) (State)
and t resided at ~U_~I~ However I have changed my domicile
(Street and Number)
ro and am and have been a bona fide ~esident of the State of Florida since _1~-- -l-f_ - day of
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_1(! d_v e/'J~1~. 19~ and I reside at ~~v U
~ (Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida_
(I~sert 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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~ F~~~p ~t~~ RECOROEO
gj. ~UC1E COUNTY FlA-
~ - ROGEk ?O~TR~S (T'~
CLERK Ct~CU1~ COURT V
~ RECORa VERtF1E0
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1 FURiHER CERTIFY that I will tomply with all other requirements of a legal resident of this State.
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I FURTHER CERTIFY that I have no intention to retum to my former domiqle, and { intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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Sworn to and subscribed before me this , day of ~~Gjt~ys~'~ . 19~
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- ~ t R I~LT ~OURT ~ Notary Public
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3y. • : D.C. My Commission expires
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(To ~~tlad in duplicate and or+ginal filed with Clerk Grcuit Cou~f, and duplicate with Tax Assessor.)
_ _ . . . . . $ 0(p( ~ti71 f'ACf ~
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