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Declaration ot DAmiCile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, ~~'~L~89
51. IUCIE COUNTY, FIORIDA:
This ~s my declaration of Dom~cile and Citizenship i~ the State of Florida that I am filing this day in accordance and
~n conformiry with Chapter 22?, Sect~on 222.17, Florida Statutes.
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I was formerly a legal resident of r..~l~ - ~ - - - - - - ~ - - - ~
(City) tate)
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and I resided at Nowever I have changed my domiCile
(Street and Number)
ro and am and have been a bona fide reside~t of the State of Florida since ~ Q V ~ ._!_.rj~'_I _ day of
i ~
~l`~v _ ~ , 19~ ~ , and I reside at - ~ / ~~~1 1 _ _
(Street and Number)
wici rie~i.E, Siaiivi L~iCie i.°vi~i~, ~`ivRivi? ~
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.)
A L, ? ~ ~o ~l e B ~~~'l4 c~
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fll.~OANQRfCURpE~
ST.lUC1E COUNTY FLA. ~
ROCE~ ?al i RAS t
CLERK Ct%:CUI~ COURT ~y c.1~
REC~R~ vEPtFt~J~t~.nC~
- J~ ~I 12 27 PN'71
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~ i fuitiNtK Cd2iirY that i wiii compiy witi~ aii other requirements of a iegai resideni of this Sia4e.
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~ I FURTHER CERTIFY that 1 have ~o intention to return to my former domiGte, and 1 intend to remain in FORT
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s~ PIERCE, SAIN7 LUCIE COUNTY, FLORIDA, permanently.
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: ' (Name)
~ . vi iv~ e,r r c o iv vP~ s o
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- ' (Address)
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~ y'~ \ f /19~
Swom to and subscribed before me this day of
?
~s
ROGER POITRAS
CLERK CIRCUI COURT Notary Public
gy l~( U.C. My Commission expires
_
(?o be executed in duplicate and ori~inal ~ilad with Clerlc Grcuit Court, and duplicste with Tax Ass6rssor.)
r~0 13 A ~OOK 1~ ~E 1513
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