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Declaration ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, ~
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Sl. LUCIE COUNTY, FLORIDA: ~
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This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and 1
~n conformiry with Chapter 222, Section 222.17, Florida Statutes. ~
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I was formerly a legal resident of ~J~1 u7"l~ .__?~t~
(City) - - - (State)
and I ~esided at _ SQ (,~*}1 1~ /1~__ _ . However I have changed my domiCile
(Street and Number)
ro and am and have been a bona fide resident of the State of Florida since ~W-~~-~ day of
~ ~~_~M _ . _ - - , 19-7_~ , and I reside at _ 3O0 N~Q_~/U ~ N6 S 1 D t 8~~- - - - -
(Street and Number)
PoQr sr. ~u~iE F~p,
FORT PIERCE, SAINT ! UCIE COUNTY, FIORIDA ( Fo Q r Pr t Qc t)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Flo~ida.
(Inse~t he~e any pertinent facts, such as sale of property or business, or relinquishment of employment
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at former dornicile, removal of family to new domicile, purchase of home, etc.) -
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S T L U~ 1 f / l-rA~lU. ~f pf~~rN~/~~y~v~tz11D,
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• . "•ROGEFi POtY~tAS ;
CLERK C~nCW~ ~G11iRi ~~`11 ~
E~~en RECORD VEr.~Ft~_...~6.:. V s
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~ ! FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
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~ I FURTHER CERTIFY that I have no intenfion to return to my former domiG~e, and I intend to remain in FORT
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PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~=,t ;
~ . (Name) ~
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300 ~
_ (Address)
~U3 Swom to and subscribed before me this ~~0 day of J A~ U 9~Y , 19
~ r~~`~'~~-, ~ ~
~yj R~~3~~2v ^ . Notary Public {
c~~ca~ewT cOu~t .
•~fe;.- .r
"=3 gy ~ D.C. My Commission expires
l ;n
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~h (To b~. Ax~c~r~~ in duplicate and ori~inal filed vvith G~rk Grcuit Gourt, snd dupliwte with Tax Assessor.)
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- .3 A s~~K 1~8 F~~~ ~318
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