HomeMy WebLinkAbout2178 Declaration ot ~omicile and Citizenship
TO THE STATE ANO COUhTY TAX ASSESSOR,
~I. Llil.lE C.UUhiiY, tllJK1UA 221960
Th~s ~s my deciarat:on ot Uom~uie and Citizensh~p ~n the Sta~e ot Florida that 1 am filing this day in accordance and
n conformity with Chapter 222, Section 222.17, Ftorida Statutes.
I was formerly a legal ~esident of ~v° L•~-~~ /`~~'j J_I ~-Q
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(City) ( tate)
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and I res~ded at 7 m~ r J~"~~ ~ v~..- . However t have changed my domicjle
(Street and Number)
•o and am and have been a bona fide resident of the State of Florida since ~T 7~_• day of
~!~-~f ~S r . 19_ 7/ , and I reside at ~ ~ i? ~ w - - -
~ (Street and Number
FORT PIERCE, SAINT tUC1E COUNTY, FLORIDA
:~nd th~s 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, pu?chase of home, etc.)
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1 FURTHER CERTIFY that 1 will comply with all other reqvirements of a legal resident of this State.
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I FURTHER CERTtFY ihat 1 have no intenTion to return to my former domic,ile, and I intend to remain in FORT
€ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. BESSIE DC. PACffi~ZA ~
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FsvZ@rn ~7d'and subscribed before me this ~ _ day of _ 19~
ROGER POITRAS -
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K C CUIT COURT Notary Public
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: By ~ D.C. My Commission expires - - ;
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(To bs executed in duplicate and original filed with Cl~rlc Circuit Court, and duplicats with Tax Assesso?.) ~
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