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Declaratlon ot Domicii~ and Citiz~nship
TO THE STATE AND COUNTY TAX ASSESSOR, 2~~
51. lUC1E GOUNTY, FLORIDA:
This is my declaration of Domicile and Citizenship in the State of Florida that 1 am filing this day in accordance and
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~n conformity with Chapter 222, Section 222.17, Florida Stetutes.
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1 was formerly a legal resident of ______~~'L
(Ciy) (Stete)
and I resided at y~i~0 rnS .
However t have changed my domiCile
(St~eet and Number)
to and am and have been a bona fide resident ot tha Stata of Florida since _Li~~~--~~-z--~--.- day of
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- - 19~ and I roside at ~Z,,~i~~. ~_!p~~Cc'~
(St~ t and Numbe~)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my deciaration of cifizenship, aciuat tegal residence and domicile in the State of Florida.
(Insert here any pertineni facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal of family to new dor»icile, purchase of home, etc.)
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1 FURTFIER CE~tTIfY that 1 will oorr~ply with atl oth~r requir~nts of a layel resident of this State. i
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I FURTHER CERTIFY that I have no intention to return to my former domic~le, and I intend to remain in FORT~ t
PIERCE, SAINT LUClE COUNTY, FLORIDA, permanently. , ~
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~ Swo~n'td'i~~~ sub3uibed before me this ~ day of ~?c~ , ~q
ROOBR ~OiTRAS
~ C~~ ro~ Notary Public ~
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aY D.C. My Commission expires i
Ro b~ ~x~ewed in e{uplieate aed eri~in~{ fil~d wNb CM~ic Cireuif Cou~t, and duplicN~ wilh t~c /1sNSSOr.)
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