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Declaration ot Domicile and Cltizensi~ip
TO THE STATE AND COUNTY TAX ASSESSOR, ~»~1~0
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51. IUCIE COUNTY, FIORIDA: ~
This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in accorderxe a~d
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerl a 1 al resideht of
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and I resided at ~ J However I have changed my domitjle ~
(Street and Numbe~) 1
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rQ a~d em and have been a bona fide reside~t of the State of Florida since / dey of ~
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19---, and I reside at !
treet and mber) 1
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FORT PIERCE, SAINT LUGIE COUNTY, fLORIDA ~
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida. ~
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(lnsert here any pertinent facts, such as sale of property or business, or relinquishment of employme~t
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at former domicile, removal of family to new domicile, purchase of home, ett.) `t
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FI~ED ANO REGOR~EO
i ST.IUCtE C01fNTY ~
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~ I FURTHER CERTIFY that I will oomply with s!1 other requirements of a legal r~sidont of this State. +
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~ I FURTHER CERTIFY that I have no intention to rotum to my former domicGle, snd I intend to remain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently. ~
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~ ,.-S~Qr~to ~kViu~iscribed before me this day of 1 ' ° ~ , 19~
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' ~ R06Ht pO1TRAS
CLFRK CIRCUIT COURT Notary Public
~'~t gY ~ D.C. My Commission expires
lTo bs axecuted in dupliut~ and original filed with G~rk Grcuit Court, and duplicat~ with Tax Ass~ssor.) ~
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