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Declaration ot Dortnicile and Cltizenship '
TO THE STATE AND COUNTY TAX ASSESSOR,
225115
Sl. IUCIE COUNTY, FLORIDA:
This is my declaration of Oomicile and Citizenship in the State of Florida that 1 am filing this day in accordance and
in conformity with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal ~esident of ~t1_~~~i~~~~
: (Ciy) (State)
and I resided at - - , - . . Howeve~ 1 have changtd my domiGle
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since . Q_~^ day of
~J"~~t~/u- 19~, and I reside at ~Q~~=l~ ~,~[~~~~-Q v.
~ (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.
(Insert here any pe~tinent 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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=~~LUCIE COUMT~~~IL
' ROCEk POIT11A3 ~~5~1S
f RECQRO YE~~FIEp COUItT
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~ 1 FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
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~ 1 FURTHER CERTIFY that I have no intention to return to my former domi4le, and I intend to remain in FORT
~
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
~
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~ (Name)
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~ = .ltoy-~9 ~~!~~~~,o c.
~ - ' : jn~:=, : ~ (Address) -
_ -
- _ - y - ` _ : ~
_ Swom to and ,iU~ibed before me this day of ,~!4~C~ , 19 7 L
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- ~06lR POI~~?S
K'CIRCUIT COURT Notary Public
By ~ D.C. My Commission expires
= Ro b~ sx~cut~d in dupliut~ snd oripinal fil~d with Cl~rk Ci?cuit Courf, and duplicate with Tax Ass~ssor.)
}~~x i.~i
No. 13A
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