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Declaration ot Dornicite and Cltizenship :
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TO THE STATE AND COUNTY TAX ASSESSt)R, 2~~~ ~
Sl. IUCIE COUNTY, FLORIDA: ~
This is my declaration of Oomicile and Citizenship in the State of Florida that 1 am filing this dav in accordance a~d
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a tegal resident of _~'~~r~Qf~L..!-_.__ __-[!t~`'S~ni~--
/ (Ciry) (State)
and I resided at _ ~S ~ ~ t a'~ _ - _ . . _ However 1 have changec! my domiG~e
(Street and Number)
to and am and have been a bona fide resident of ihe State of Florida since l~c.t. ~O ~_!_Q?1 day of
- - - 19~1_, and I reside at _~s3_ •.fov~f.i. ,2~ ~ J1~ l~s~ r'i~e ~e,.- -
(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.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of famity to new domicile, purchase of home, etc.)
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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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~ 1 FURTHER CERTIFY that I have no intention to return to my former domic,ile, and I intend to remain in FORT
~ PIERCE, SAINT LUGE COUNTY, FLORIDA, permanently.
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: . . - _ ~ - ~
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~ (Name)
, , Leroy W. Bracey
- .~li~~ .2~1 S ~
- . ~ (Address)
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Sworn ;p and subscribed before me this ~ day of , 19~~`-
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- - 1
ROGER POII'RAS ~
C~ CIRCUIT COURT Notary Public
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By D.C. My Commission expires ;
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`L~ (To bs ~xecuted in dupliute and original filed with Cl~rk Grcuit Court, and dupliut~ with Tax As~ssor.j
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