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Declaration ot Domicile ansl Citizenship ~~2r2318 i
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TO THE STATE AND COUNTY TAX ASSESSOR, '
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Sl. lUC1E COUNTY, FLORIDA: {
This is my declaration of Domicile and Citizenship ir~ the State of Florida that 1 am filing this day in acco~dance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
I,on Branch l~ew Jer~e
I was formerly a legal resident of - - _ - _ _ - -
~C~~y~ (State)
and I resided at 264 WBS~_ ~id _A~@. _ . However 1 have changed my domicjle
(Street and Number)
ro and am and have been a bona fide resident of the State of Florida since _ ~ 5th day of
__Ya1_ . _ _ _ _ 19
T~ , and I reside at 605 _SO. 29th St ~ 1~'t. Pieres_:_ ~'1.
(Street and Number)
FORT PIERCE, SAtNT LUCIE COUNTY, FtORIDA
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 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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RESIDENCE
fIIEG 1~y~ R~~OR~~~
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' CLERK L:~:~'J1t CO
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~ 222318
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1 FURTHER CERTIFY that I will comply with all other requirements of a iegal resic~ent of this State.
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~ I FURTHER CERTIFY that I have no intention to retum to my former domiqle and I ntend to remain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ (Name)
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- , , : _ _1605 So . 29th St . , Ft. Pi erae, ~'1.
_ ~ ~ . . . (Address) 33450 -
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Sworn to ani7: sobac~ibed before me this ~ 8th day of J~u~~ , 19 72 . ;
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_ ~ ~•4 DQE1j' ~OITRAS - -
~ ~C~~C~tJIT COURT Notary Public
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By D.C. My Commission expires
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~~s (To bs ~x~cut~d in duplicate and ori~inal fil~d with CIKk Gircuit Court, •nd dupliut~ with Tax Ass~ssor.)
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