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Declaration ot Domicite and Citisenship
TO THE STATE AND COUNTY TAX ASSESSOR, 2?~~5~ ~
Sl. IUCIE COUNTY, FIORIDA ~
This is my declaration of Dom~cile an;; c;ititenship in the State of Florida that I am filin9 this day in accorda~ce and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
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I was formerly a legal resident of ~
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~C; ry~ (State)
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and I resided at ,~i-1
_C.~'~~C~~% _ /!~_~~2 ~__1~~~. However 1 have changed my domic,ile
(Street nd Number)
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ro and am and have been a bona fide ~esident of the State of Flo~ida since - day of
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t~~ t-cr11L _~'L~ , 19~~ , and I reside at ~4-~ . ~y> ~ .
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my detlaratior~ of citizenship, actual legal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of prope~ty or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc_)
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~ f LED AMD RECOROEO
a~• IUCiC GOUNT~ Fu.
ROCER P4t;R~g
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COU~~
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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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I FURTHER CERTIFY that I have no intention to retum to my former domiule, and I intend to remain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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:$yirott~ to:e~?d'•~cribed before me this day of ' , 19~~
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ROl9E~'' ~ITRAS
CLERK GiRCUIT OURT Notary Public
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- By < _ D.C. My Commission expires
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" (To be executed in duplicate and original ~iled with Cl~rlc Grcuit Court, and dupliwte with Tax Assessor.)
- d00K ~~70 PAGE
s:' 1469
- *dc 13 A
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