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DeClaration ot DomiCile and Cltizenship
TO THE STATE AND COUNTY TAX ASSESSOR, i
Sl. LUCIE COUNTY. F~oR~oA: 221354
This ~s my declaration of Domicile and Citizenship in the State of Florida that 1 am fili~g this day in accordance and
~n conformity with Chapte? 22~, Section 222.17, Florida Statutes.
I was fo~merly a legal resident of ~ _ _ . - _ _ '
~ (City) (State)
and 1 resided at ~l/D ~A~~sczu However I have changed my domiCile
(Street and Number)
~o and am and have been a bona fide resident of the State of Florida since day of
~ .
19_~~, and I reside at _~Ul_----1~~~~~ l~ r~ S r
(Street and Number)
FORT PiERCE, SAINT LUCIE COUNTY, FlOR1~A
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, remova! of family to new domicile, purchase of home, etc.)
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~ I FURTHER CERTIFY that I will comply with all other requirements of a leyal resident of this State.
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~ I FURTHER CERTIFY that I have no intention to retum to my former domiCule, and I intend to remain in FORT
~
PIERCE, SAINT LUCIE COUNTY, FLORIDA, pe~manently.
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~.Q'~f~itv ,
~ (Name)
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DQ S G. ,y~p~r. ~v s
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Sworn~~~ suburibed before me this ~ day of ~ ~ L-~ 19~~ _
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:a ' • ~ . ~O~'~~OITR/45 1
~ ~{G`t.~~ ZtRCUIT COURT Notary Public 1
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By , D.C. My Commission expires ~
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~=4 (To b~ ~xecuted in dupliute and ori~inal ~il~d with C{~rk Circuit Court, and duplicat~ with Tax Ass~s~or.)
-k~ p goo~ 198 1326
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