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~e~Claration ot Domicilg and CitizenshiR
TO THE STATE AND COUNTY TAX ASSESSOR. 222393 ~
51. lUC1E COUNTY, FIORIDA:
This ~s my declaration ot Dom~cile and Citizenship in the State of Florida that 1 am filing ?his day in accordance and
~n confo?mity with Ch3~ter 222, Section 222.17, Florida $tatutes.
I was formerly a legal resident of ~~~~~2~ - Ls-!~-~"-'~`'~~-~
(City) - - - (State) - ~
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and 1 resided at _ ~ r l1 ~~G~--_y~ - Nnwever I have changed my domiGle
~ (Street and Number) ~
fo and am and have been a bona f~de resident of the State of Florida since (O - day of
~1, ~ , . •
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- - - , 19._7~ , and I reside at __---5 . ~
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domic+le in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at fo~mer domicile, removal of family to new domicile, purchase of home, etc.)
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~ 222393
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~ 1 FURTHER CERTIFY that I witl eomply with all other requirements of a legal resident of this State.
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~ 1 FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
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~ ~~cR~c, SAlNT LUCIE COUNTY, FLORIDA, permanenNy.
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(Name)
' . , ~ ~ L. ya~e wRo4~-~?
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_ • . (Address)
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= Sworn' b and subscribed before me this ~ G day of -
i;
ROGER POITRAS -
CLERK CiRCU1T COURT Notary Public
g ~ z Ss~~ ~ D.C_ My Commission expires
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(To be exscut~d in duplicats a~d ori~inal ~led with Cl~rk Circuit Court, and dupliuts witl~ Tsx Ass~ssor.)
= a~~198 ~2775
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