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Deciaration ot Domicile and Citizenship
TO TFiE STATE AND COUNTY TAX ASSESSOR,
Sl . IUCIE .COUNTY, FIORIDA: IGr~~~O
This ~s rny declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordante and
~n conformity with Chapter 222, Sect~on 222.17, Florida Statutes.
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I was formerly a legal resident of « T- ~l
(City) (State)
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a,tid I resided at .~%71~~ _~_T However 1 have changed my domiGle
(Street and Number)
ro and am and have been a bona fide ~esident of the State of Florida since ~L day of
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- 19
~r_, and I reside at 7l~ ,c;~ ~ I ;
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence a~d domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of prope~ty or business, or relinquishment of employment
at former domicite, removal of family to new domicile, purchase of home, etc.)
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~ FIlEO A~~ OvNTY flA.
~ , ST. LUC~E ~
!Z ; _ _ _ ~ ~ ROCER PO?TRAS
~U ~~ERK CiaC1l~T COURT ~
. RECORO VER1f1E~~
f . . - ~ / DEC ~ ~ S4 ~ ~
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= I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
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_ I FU4TNER CERTIFY that I have no intention to retu~n to my former domiGle, and 1 intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~~2~.~ 7/~~~~~.., ~'~~u..~ `~~~~.:.a
(Name)
- ?iAni fr1 A~~ ~ Z'~~'~ ~ ~ N S
(Address)
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' Sworn to anaLr~,bxri~ied before me this day of . 19~-
- s.4C~R ~QJTRAS
: C~'
GIRCUIT COUttT Notary Public ~
By D.C. My Commission expires '
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~ (To be exscyE ~in duplicate and o~iginal filed with Cle?k Circuit Court, and duplicate with 7ax Assessor.)
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