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Declaration ot Domtcile a~d Cltisenship ~
~6163 ~
TO TNE STATE AND COUNTY TAX ASSESSOR,
Sl. WCIE COUNTY, FIORIDA~
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This is my declaration of Domicile and Citizenship in the State of Florida that I am filing this day in accordance and
~n conformiy with Chapter 222, Section 222.17, Florida Statutes.
I was formerly a legal resident of
(6(ry) - (State)
and I ~esided at _~L~_Z N~i /4~L',! e_~'~~_R_7 ?G__`___ _ _ . However I have changed my domic,ile
(Street and Number)
!o and am and have been a bona fide resident of the State of Florida since ._.~jA~PC/j day of
_ 19 and I reside at _~¢_Ql_-.d----A~1~~s°A -_.,c'~?_-G_--- -
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, RORIDA
and this statement is to be taken as my declaration of citizenship, actual lega) residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of propery or business, or relinquishment of employment
at former domicile, removal of family to new domicile, purchase of home, etc.)
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CLERR CIRCUtT COWtT `
RECQR~ VER;FIEO.~~,,,,~ j
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~ I FURTHER CHtTIFY that I will comply with all other requirements of a legal resident of this State. ~
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~ I FURTHER CERTIFY that I have no intention to return to my former domiGle, and I intend to remain in FORT ~
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: PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
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~ ' (Name) ~
r . ~ ~ ~ Eaton 0. I~oltz #
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_ -l5wor~'.~4~~rld subscribed before me this ~ ~ day of ~ ' ` , 19~i
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ROGER POITRAS
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CIRCUIT COURT Notary Public
By !`-t ~ O.C. My Commission expires
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~ (To bs axecut~d in duplicate and origina! ~iled with Clsrk Grcuit Court, and dupliwt~ with Tax Assessor.)
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