HomeMy WebLinkAbout2080 DeClaration ot DomiCile and Citlsenship 22603~
TO THE STATE ANO COUNTY TAX ASSESSOR,
51. LUCIE COUNTY, FLORIDA:
This is my declaration of Domic?le and Citizensh~p in the State of Florida that 1 am filing this day in accordance and
~n conformity with Chapter 22?, Section ~22.17, Florida Statutes.
I was formerly a legal resident of '~a"s `~L `7 a: c E- f t- ' ~ llc=u~ 7 i..E ~
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1 (City) tate)
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and I resided at ~ ~ ~ ~ T_ ~f _a L~' _ However I have changed my domi~ile ~
(Sireet and Number) ~
!o and am and have bee~ a bona fide resident of the State of Florida since Ll+~-"~ ~Z- _1~~~- day of ~
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' ~L. L~z ~ - , 19~~ , and 1 ~eside at C~ Ii _ l _ ?._2 a < t1 ~ • _
/ ~ treet and Number)
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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 property or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etcJ
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~ SIl/SIDE~'CE ~EO AND Ilt~ R E a
WCIE CGUt~~i~~' ~ ~
~OOER P01 ~ ;
ClE1lK ~~S~~~T COURT•~~ ~
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~ I FURTHER CERTIFY that I will comply with all other ~equirements of a legal resident of this State.
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~ 1 FURTHER CERTIFY that I have no intention to return to my former domiCile, and I intend to remain in FORT
~ PIERCE, SAINT LUCIE COUNTY, FIORIDA, permanently_
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~ Y r~ tc E fl ~ t sM~ ~3FRPl`~~3/V
, (Name)
YMKJE HAISMA BERG~'AN ~ '
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Svvom to and subscribed before me this _ 22nd day of - MBrCh__ , ~q 72 _ ~
ROGER POITRAS
K IRCUIT COURT Notary Public =
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By D.C. My Commission expires
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_ (To be executed ie duplicsie and original filed with Cl~lc Grcuif Couuf, :nd duplicale with Tax Assessor.) #
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