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Decla~ation ot Domicile and Cittze~ship
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TO THE STATE AND COUNTY TAX ASSESSOR,
51. IUCiE COUNTY, FLORIDA:
This is my declarat~on of Dom~ci?e and Citizensh~p in the Sta~e of Florida that I am fil~ng this day in accordance and
:n conformiry with Chapter 222, Section 22?:17, Florida Statutes.
1 was formerly a lega) resident of _ _ . ~H~jQ21 - - - ~
~C~ty~ (State) ;
and 1 resided at _ ~O_~8~I1__StTe6t _ However I havechanged my domicale
(Street and NQcn. ber) r
i
ro and am and have been a bona fide resident of the :,tate of Florida since _ _ 22Il~__ - day of ~
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Ile_ce~Z?@r _ l9 and t reside at _ -2~~--- Qhe2VlitO~d • np -
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIOA
a~d 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, ~emoval of family to new domicile, purchase of home, etc.)
222382
fi~E~ aye ~ECOaaeo
Establishing reaidenee sT.~uc~F co~NrYfu
it0'viF PD~TRAS
CLERK C1~ ;;JI' COURT
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~ ~At~! ~0 ~:28 AH'7Z 7~~/
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~ 1 FURTHER CERTIFY that I will cornply with all other requirements of a lesal resident of thia State.
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I FURTHER CERTIFY that 1 have no intention to return to my former domiule, and I intend to remain in FORT
~ PIERCE, SAINT IUGE COUNTY, FLORIDA, permanently.
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5 . . . ~ (Name)
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_ ~ ; . Bet y Bracken ( ~rs Stanley
' (Address)
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- Swom to and subxribed before me this -_~tb day of - _~TEI?~~~ , 19.~.~_• ~
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ROGER POITkAS - -
K ClRGU1T COURT Notary Public
y;: Sy _ D.C. My Commission expi~es
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(To b~ execvted in duplicats and or'sgi~~l filed with Cl~rlc Grwit GQyrt, and duplicate witl~ Tax Ass~ssor.)
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