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TO THE STATE AND COUNTY TAX ASSESSOR, ~~~~rO~ '
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Sl. IUCIE COUNTY, FLORIDA:
This is my declaration of Oomicile and Citizenship in the State of Florida that I am filing this day in accordance and
~n conformity with Chapte~ 222, Section 222.17, Fto~ida Statutes.
I was formerly a legal resident of __L ~L_~.~_ ~~~s r~~ ~I/-~ w Y
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and 1 resided at _ However I have changed my domiCi~e
(Street and Numbe~)
to and am and have been a bona fide resident of the State of Florida sinte _.1L~_" day of
-~1~~~ . 19~~, and 1 reside at z~~ 5~~~~ U~~I/•~`
(Street and Number)
fORT PIERCE, 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.
(Inse~t 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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~ ~i 19 JI 03 ~'T
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~ 1 RJRTHER CERTIFY that I will oompfy wiffi all othet nquirements of a le~al resident of this State.
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~ 1 FURTHER CERTIFY that I have no i~tention to retum to my former domicjle. and I intend to remain in FORT
~ PIERCE, SA1NT LUCIE COUNTY, FLORIDA, permane~tly.
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~ y~ ~ ~vor~ t~ ~scribed before me this day of , 19 7?~
A S4~ , ::~f{#y ?
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,s :;~,;~<<~~is~;~j~sl~r~
s ~ ~IRCUR~ COURi Notary Public
= By ~w D.C. My ~ommiuion expires
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~ (To b~ ~x~nrl~d in caN sed
~ d~pii ori~i~al fil~d wj1i~ Cl~k Ci~i~ Co~rt, and d~rpljc,ata wilb Tax Asws~or.)
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