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DeClaratio~ ot DomiCile and Citisenshlp ~
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TO THE STATE AND COUNTY TAX ASSESSOR. ~ ~ ~39
Sl. IUCIE COUNTY, FLORIDA: '
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This is my declaration of Oomicile and Citizenship in the State of Florida that I am filing this day in acco~dance and
~n conformity with Chapter 222, Section 22~.17, Flo~ida Statutes.
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1 was formerly a legal resident of _ _ _ ~ _ _ _ _ . _ - - -
(City) (State)
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and I resided at _ _ ~ ~
_ _ _ . _ . Nowever ! have changed my domiCile
(Street and Number)
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to and am and have been a bona fide resident of the State of Florida since _ L..__ day of
- _ - - 19~~ and I reside at X„~ B _ _ ' 71l.~'~~.~~s- -
~ (Street and Number)
FORT PtERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida. ,
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(Inseri here any pertinent facts, such as sale of property or b~siness, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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~ I FURTHER ~ERTIFY that I will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return my former domicjle, and I intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently_
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~ =''t - - / '~f (Name)
~ altY t • t '.~`rr' . }~r . ~p I'~ ~l . P ~EC ~QW Sk~
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t~ ~t(~ 3U6scribed before me this day of - _ , 19~1~
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~~f ~OGER''!i'biTR/C5
~ q~JtK CIRCUR COURT N~tary Public
~ By ~ G O.C. My Commission expires
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; Ro b~ ~x~cut~d in dupliut~ and oripiesl filed with Cbrlc Cirwit Court, snd dupliuf~ with Tax Ass~s~or.)
~o$~c1~ ~~I16~ - ~ ~
,"`~v No- 13
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