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221636
Declaration ot DomiCile and Citisenship
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TO THE STATE AND COUNTY TAX ASSESSOR, ~
Sl. IUCIE COUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a legal resident of~Q7'L . _ - - - - -
; tate)
~ (C tY)
and 1 resided at .~O Q~J ~~~t~l~ ~C~. ~~~~~_.!-~]^~C~ However 1 have changed my domi6ile ?
(Street and Number) ~ . 4
ro and am and have been a bona fide resident of the State of Flarida since _ , _ - _ day of
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~ ~ , 19l__ _ and I reside at l _ ~
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
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 pe~tinent facts, such as sale ot property or business, o~ relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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~ 221636
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~ I FURTHER CERTIFY that 1 will comply with alt other requirements of a lega) resident of this State.
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I FURTHER~CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
~ :~IREIkLE P. IS CSON
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~ (Name)
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+yYy . • ,
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- Swor.n to~erid~subscribed before me this _ a~ day of , . 19 7 •
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~ ROGER POITRAS - - -
~'F CLERK C IT COURT Notary Public
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z'; By _ ""I__ D.C. My Commiss~on exp~ras
(To b~ ~xecuted in duplicate and originsl ~ilsd with Cltrk Circuit Cou?t, and duplicst~ with Tax Assessor.)
dOCK~90 PAGE~7O~
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