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Declaratio~ ot Domicile and Citisenship ;
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TO THE STATE ANQ ~OUNTY TAX ASSESSOR, •
Si. IUCIE COUNTY, FIORIDA: ~IZSSSI
This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and ;
~n conformity with Chapte~ 222, Section 222.17, Florida Statutas. !
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I was formerly a legal resider~t of -
(Cify) (S ate)
and 1 resided at _ _ _ _ However 1 have changed my domic.ilc
(Street and Number)
to and am and have been a bona fide resident of the State of Florida since _ v'~ 'day of
~ ^ L _ ~ ~ 19~~, and I reside at ' _ _
-
(Street and Number)
FORT PIERCE, SAINT LUCIE 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 properry or business, or relinqbishment of employment
at former domicile, removal of family to new domicile, purcfiase of home, etc.)
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~ 1 RIRTHER CERTIFY that I will camply with al) other requirements of a leyal resident of this State.
~ I FURTHER CERTIFY that 1 have no intention to retum to my former domiCile, and I intend to remain in FORT ~
~ PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ . . . . _ , Rc (Name) L~.6~Qi
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_ ~ ~ (Address) ~
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_ Swcra to and suburibed before me this day of l~ u~ , 19 ?
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" ROGHt POITitAS ~
'j; CLFRK CIRCUIT COURT~ Notary Public F
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By D.C. My Commission expires 3
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~ (To b~ ~x~arhd in dupliub and orip~nal filsd with Cls~lc Grcuit Court, and duplicat~ with Tax Ass~stor.)
;aA 6GRK~OQ P1,CE~378
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