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Declaration ot Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, ,
. 3
51. IUCIE COUNTY, F~oR~oA: 22135'7 ;
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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 '
~n conformity with Chapter 222, Section 222.17, Fforida Statutes.
1 was formerly a legal resident of _ ~~(c(~` - - - - - -`~~~j-Z_~~ -
(State)
anc~t resided at ~~Tr~,d!_'~~ __L!Y ___~L~ s~~owever I have changed my domiCile
(Street and Number)
to and am and have been a bona fide resident of the State of Florida sinte ~~U-+~~ ~`3 - day of
- - , 19~~ and I reside at ~_---sL~~~ Ce ~v~~~ < `~Gr'~
(Street and Numbe~)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in ihe State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment ,
at former domicife, removal 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 legal resld8nt of this State.
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~ I FURTHER CERTIFY that I have no intention to ret~rn to my former domiule, and I intend to remain in FORT
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~ PIERCE, T LUCIE COUNTY, FLORIDA, permanently.
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= Swom to and subscribed before me this day of 'nt< << , 19~
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- ROC~ER PQITRAS
CLERK CIRCUIT COURT Notary Public
By C U~ D.C_ My Commission expires
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- (To bs executed in dupliute and original filed with Cl~rlc Grcuit Cour1, sn~ duplicate with Tax Assesior.)
° R 198 13~'9 '
No 13 A d~K ~fiE
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