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Decl~ration ot Domicile and Citisenship =
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TO THE STATE AND COUNTY TAX ASSESSOR, ~ 224942
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Sl. lUC1E COUNTY, FLORIDA:
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This is my declaration of Oomicile and Citizenship i~the State of Fiorida that 1 am filing this day in accordance and ~
~n conformity with Chapter 22Z, Section 222.17, Florida Statutes.
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I was formerly a legal resident of __Y_____
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(City) (State)
and 1 resided at 1. ~ _ ~ _ _ _ _ However 1 have changed my domiCile ~
(Street and Number)
to and am and have been a bona fide resident of the State of Fbrida since day of
19~1 , and I reside at .~3 ~ / ~ .
(Street a Number) ,
FORT PtERCE, SAINT LUCIE COUNTY, RORIOA
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 busi~ess, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
I~ ~ 3t~01N0 RE.~p
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R O~iTRAa~
CIERK C;~CUIT ^
RECOFp yERrF~Ep C~
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~ I FURTHER CERTIFY that I will oomply with all other requirements of a leyal resident of this State. j
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~ I FURTHER CERTIFY that I have no intention to retum to my former domitile, and I intend to remain in FORT
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~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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. i Sworn.+~~ld subscribed beforc me this day of ~ _ ~ , 19 .
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. ' ~ ~OITRAS -
CLFRIC CIRCUR COtMT Notary Public
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~ By _ D.C. My Commission expires
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(To 6~ ~x~cvt~d in dvplicaN and orioinal fil«! wili~ CIMk Graril Cour~, ~nd dvpliut~ wilh Tax Ass~s*or.)
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