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Declaration ot Dornicile and Citizenship
TO TNE STATE AND COUNTY TAX ASSESSOR, ~~~QC~
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~1 IULiE l.Vl1~l i Y, tilJK1IJN.
Th~s ~s my detlaration of Dom~ufe and Citizenship in the State of Florida that I am filing this day in accordance and
n conformity with Chapter 22?, Section 222 17, Florida Statutes.
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I was formerly a ~egal resident of ! ~~"!'G~ i¢~' ~~t -
~C;ty) (State)
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and 1 res~ded at _ _ _ ~ However I have changed my domic,ile ±
(Street and Number)
!o and am and have been a bona fide resident of the State of Florida since day of ~
~
1 ~ / 3 ~A~S~~
_ ~ , 19~! , and 1 reside at _ - _ IT_. -sC^ -
(Street and Number)
FORT PIERCE, SAINT lUC1E COUNTY, FLORIDA
and this statement ~s to be taken as my declaration of citizenship, actuai 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 domiciie, removal of family to new domicile, purchase of home, etc.)
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N 1 FURTHER CERTIFY that 1 wil) comply with a!I other requirements of a legal resident of this State.
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~ I FURTHER CERTiFY that 1 have no intention to return to my former domicrle, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently_
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Swor~ .to•aktd subscribed before me this day of _ , 19~_
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= ROGER POITRAS
CLERK CIRCUIT COURT Notary Public
y4~~ By - v`C~~-~- D.C. My Commission expires
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(To b~ executed in duplicate and originai filed with CIKk Grcuit Courf, and dupliut~ with Ta~ Ass~ssor.)
B~~K 1y8 ~ 21'17
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