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Decla~Ation ot Dor~icii~ a~d Citisenship
TO THE STATE AN~ CO~INTY TAX ASSESSOR, 2~~82 !
Sl. IUCIE COUNTY, flORIOA:
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in acco~dance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes. -
I was formerly a legal resident of _ _ . _ _ ~ _ _ _ _ . - _ ~--L`-! '
(City) (State)
and 1 ~esided at _ _.~G ~~._Z_ ___..l~~~1~_ _ _ _ However I have changed my domiCile
• (Street and Number)
to and am and have been a bona fide resident of the State of Florida since _ ~ 7 ~tr~ day of
Q C ~E~ - - , 19
7 ~ and I reside at ~7 ~_L
~~l ~~/~L.rT ~ .S G?_ ~•l
_L ~ y
(Street and Number)
;
FORT PIERCE, SAINT lUC1E COUNTY, fLORIDA
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.)
224282 _
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~ 1 FURTHER CERTIFY that 1 will comply with all oth~r requirementt of a le~al resident of this State. ~
~ ~
~ I FURTHER CERTIFY that I have no intention to return to my former domicile, and 1 intend to remain in FORT
~
F PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
~
~
~ - • / _
~ _ • ~ ~
~ - _ (Name)
; ~
.
- -
• - - (Address)
_ -
_ ` ••v;~• ~ 7
Sworn to.and subxribed before me this day of ~'G~"t-«-_'t_`u'` , 19L~?--
s.
;3
ROGER POITRAS _
_ K CIRCUIT COURT Notary Public
0~-~1~- °zc~-~.~z~
~ 8y D.C. My Commission expires
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(To b~ ~xecut~d ie duplicab and oripinal fil~d with tl~rlt Grcuit Ceurt, and duplicsh with Tax Ass~ssor.)
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