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Declaration o! Domicile and Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR, 2~6513
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Sl, IUCIE COUNTY, FIORIDA: ~
This is my declaration of Oomicile and Citizenship in the Sta~e of Florida that I am filing this day in accordance and
~n conformiry with Chapter 222, Section 222.17, Florida Statutes.
I was formerty a legal reside~t of _ ~'~d ' ~
(City) (State)
and 1 resided at ~.~-`V`~ Howeve~ 1 havr changed my domiGle
(St~eet and Number) ~ ~
to and am and have been a bona fide resident of the State of Florida since _ / day of
~i~1~P. ~ c
____1L~~~^___ , 19~~, end 1 reside at `
(Street and Number)
1'
FORT PIERCE, SAINT lUC1E COUNTY, FLORIDA
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and this statement is to be taken as my declaration of citizenship, adual legal residence and domicile in the State of Florida. -
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(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
~ st former domicile, removal of family to new domicile, purchase of home, etc.) ~a
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226513 ~
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IIECO D YE1l1itE0..•.~••••••
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~ I FURTHER CERTIFY that I will aomply with all other requirements of a legal resident of this State.
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~ I FURTHER CERTIFY that 1 have no intention to retum to my former domic.ile, and I intend to remain in FORT
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~ PIERCE, SAINT WCIE COUNTY, FLORIDA, permanently.
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~ : . ; . ~1-~~e.eL~,.... ~ 9~1~~-~.-~ ~
_ ~.a~: , - (Name) ~ ~
~ ~ , - - Nillian C ~Yorrell
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! ~ G~ .l~v~.C ~ G~'t~L
_ • _ • ~ (Address)
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, ;C•~ . ~ ' - 30th y March
= Swqfh tb~and subscribed before me this da of , 19 72 . ;
N.j~ ~
ROGER POITRAS ;
K CIRCUIT COURT Notary Public `
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By ` D.C. My Commission expires ~
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(To bs sxecuttd in duplicsts and origina! ~ilsd with Cl~rk Circuit Court, and duplicats with Tax Assesso~.)
~t; 600!(~VV PACE27~
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