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Decla~ation ot Domicile and Citizenship
TO THE STATE AND COU(~TY TAX ASSESSOR, ~1~`~ ~
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Sl. LUCIE COUNTY, FlOR10A: i
This is my declaration of ~omicile and Citizenship in the Sta~e of Florida that I am filing this day in accordance and
~r, conformiry with Chapter 222, Section 222.17, Florida Statutes.
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t was formerly a legal resident of - ;
(Ciy) ( te) ~
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and I resided at p~(p_ P 3 _~Q!_L~ . However 1 have changed my domiGile
(Street and Number).
ro and am and have been a bona fide resident of the State of Florida since ~f day of
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/'L~Cd- -ir_. _ _ 19~~-, and 1 reside at - ~~a`„1' - ~ - -
(Street and Number)
PORT PiERCE, SAIN? 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 family to new domicile, purchase of home, etc.)
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~ f1~EO ?Ne aECOq~EO
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c~~aK c~pL~~z ~ouat
t aFc'ORf FIF~ED~.~.~•••"'
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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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~ t_ FURTHER CERTIFY that I have no intention to retum to my former domiuie, and 1 intend to remain in FORT
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~ PIEf~,~SAj~~1E COUNTY, FLORIDA, permanently.
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a~` . ~ ' . ~
~ ~ ` Billie ean Aea~
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: • - ; . " . ' ~ ~ (Address)
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Sworn to and subscribed before me this ~ day of 4~"~` , 19~?-
~ ROGER POITRAS
K CIRCUfT COURT Notary Public
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=7=; By f D.C. My Commission expires
(To be ~xecuted in dupliate and original ~iled with Cl~rk Circuit Court, and dupliat~ with Tax Assessor.)
g~K 138 F~~ 1317
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