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Declaratlon ot Domicile and Cttlsenship
TO THE STATE AND COUNTY TAX ASSESSOR, ~y
11i//Gr•3~
51. LUCIE COUNTY, FLORIUA:
This is my declaratio~ of Domicils and Citizenship in the State of Florida that 1 am filing this day in attordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerl a I al resident of ~t C~ t 3' v _
Y ~9 -
(Ciy) (Staro) i
and 1 resided at _L_ 1 ~_e w_ ~ r t~~ However I have changed my domiCile
(Street a~d Number)
ro and am and have been a bo~a fide resident of the State of Florida since a__ S~~~ day of
yys~ s;.~~, D
- - 19 and I reside at
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA
and this stateme~t is to be taken as my dedaration 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 employme~t
at former domicile, ~emoval of family to new domicile, purchase of home, etc.) ~
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: 1 FURTHER CHtTIFY that 1 will oomply with all other requirements of a leyal resident of this Stata.
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~ 1 FURTHER CERTIFY that I have no intention to return to my former domiCile, and I i~tend to remain in fORT
~ PIERCE, SAINT LUCIE COUNTY, FIORIDA, perman8ntly.
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T/'~/_~ /tJ G~2~F-c•w..? ~
~ ~ ' ' • MRS . BARBARA~ ~fAYHEIf
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_ . . " . " Wddress)
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_ ~ f; _~v~jn b aei~ ~ul~Cribed before me this "r day of / v" , 19~
- ROG~ POITRAS
j 1 UIT COURT Notary Public
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: By D.C. My ~ommission expires
Ro bt ox~evfrd in dupliul~ and ori~nal fi~d wiTh Cl~eie Ge~a~if Court, and dupliut~ with Tax Assrs~or.)
, 3 A ~oa~ 200 ~ 445
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