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De ~aration ot Domicils and Citizenship 22 ~ 5J4 ~
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TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. lUClf COUNTY, fIORIDA:
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This ~s rny declaration of Dom~c~le and Cit~zenship in the State of Florida that 1 am filing this day in ac:ordance 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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(City) ate)
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and ! resided at ~ . / ~'E ~ a/~/ . _ _ _ _ _ _ However I have changed my domicjle
(Street and Number)
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~ ro and am and have been a bona fide resideM of the State of Florida since /~^t~~ I _ day of
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- . 19~~ , and I reside at ~ i3o•~ ~'~/N/yN/~
(Stre~t and Number)
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FORT PIERCE, SAINT LUCIE COUNTY, FLORlDA
and this statement is to be taken as my decla~ation of citizenship, actual legal residence and domicile in the State of Florida.
(Inserf 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.) ?
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22j~9~
FILED AN^ RE~ORDED
ST.IUC![ CGUNiY F~A.
! ROGEr~ ~ •~IT~2AS
CIER!( C:'~;:;;T ~OURT
RE;.r,3~ y: . f tE~
= J~+ 6 9 0~ AN '7
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~ 1 FURTHER CERTIFY that 1 will compiy with all other requirements of a legal resident of this State.
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~ I FURTHER CERTIFY that 1 have no intention to return to fo er domi~ile, a I i e~ to remain in FORT
~ P!ERCE, SAiNT LUCIE COUNTY, FLORIDA, permanently.
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~ - - (Name)
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,~30 ~ ~~~,l--,L9,v ,U~~
_ (Address)
Swom to and subscribed before me this day of , 19
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= ROGER POfTRAS
_ CLERK CIRCUIT COURT Nota: y Aub4ic ~~~~~j~~ N~~ Y
' ore. t~n
- BY - - D.C. My Commissiop•~xpires':~~3-'~ ""'kM ~
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(To be executed in duplicate and original filed with Cl~rk Grcuit Cour~,~.and duplicst~ v~[hi~~Tax Assessor.)
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~~K198 ~f1645 ~ . . ~ E
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