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Decla~ation ot Domicile and Citizenship '
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TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, F~oR~oA~ 2222'~'~
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Th~s ~s my dec~aration of Domic~le and C~tizensh~p in the State of Florida that I am fil~ng this day in accordance and `
~n conformity w~th Chapter 222, Sect~on 222.17, Florida Statutes.
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1 was formerly a legal resident of ~ _ -
(City) ate) '
and I resided at J°t ~ _ . Nowever t have changed my damiCi~e
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(Street and Number)
ro and am and have been a bona fide resident of the State of Florida since - day of
_ - - . , 471--, a.,~ ~ .~~~~ie rt /~i~ / 1~ •r'-y~ S, e~. P,c f~zc~,,
`~L~~ (St~eet and Number)
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FORT PIERGE, SAINT IUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of utizenship, actual fegal residence and domicile in the State of Florida. ~
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(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.)
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Sf l C ~ COUMTY
, 1~~ _ _ AGC~nFJIiRAS
, /TU`"c-~-c..t CLERK CtKCJ~T COt1RT
RFCORl1 yc•-.i~lF~J ~
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' ~r+ I~ 9 4s AH '11
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! FURTHER CERTIFY that I will comply with all other requirements of a legai resident of this State.
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1 FURTHER CERTIFY that I have no intention to return to my former domicjle, and I intend to remain in FORT
PIERCE, SAINT LUGE COUNTY, FLORIDA, permanently.
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' (Name)
~:2 ~~1~e r2 i c Ir l~e / Jr
(Address)
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Srwtt~:~q;;~+~d,~ubscribed before me this day of , 192c~.
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.d~ERK C~tC`l~l~t1R Notary Public
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6y. ' I'~~ D.C. My Commission expires
: :E. R~,`" •
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~ j'~l~r•~ it~ dupliute snd original ~il~d with G~:k Grcuit Courf, and dupiicats with Tax Ass~ssor.)
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