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Deciaration of Domicile and Citizenship ;
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TO THE STATE AND COUNTY TAX ASSESSOR, '~34S~S !
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~T. lLr~,~=t COUNTY, FLORiDA: ~
71~ii is my declaration of
Domicile and Citizenship in the State of Florida that ! am f7ling this day in
accordance, and in r.onformity with Section 222.17, Florida Statutc~s.
! was ~'ormerly a Iegal rc~sideni of SO 1~V.~/~~~f- and I
~ 3 ~03 Su.~ - «,~y~ ~S~a«,
resided at S~/_~/~ . . However, I have changed my domicile to
(Stteet and Number)
and am and have br;en a bona lide resid~nt of the State of Florida since ~ day of ±
~1~~. _ , 19--~, and I reside at ~ ~1' _
n (Street and Numbcr)
./"~'E'2 C~ _ , ST L NG~t-~ County, Florida,
(c~tr)
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State
of Florida.
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• (Insetl here any pettinent facts, such u safe of property ot businr.ss, or relinquishment oi employment at [ormer r ~
domicile, removal oi famity to new domicile, purchase ot Rome, etc.) 1
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SL LUCIE COttN1Y f~ 't,
ROCEP FOITRAS ~
CIERI( Cl3~~~T ~p~RT
REC~R~J VERrF~EO.~~`
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1 FURTHER CERTIFY that [ wi(I register at my local address when the registration bool:s reopen, and ~
comply with all other requirements of a legal resident of this State. ;
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I FURTHER CERTIFY that 1 have no intention to return to my former domicile, and 1 intend to remain in ~
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GIG.I L ^ , County,
~ Florida, permancntly.
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p-;~;; mhomas Ferry Herrlett
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S~lvorn #o anc~3ubscribed before me this day of
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~ ~ A.D. 19ZZ . #
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otary Public State brida at largc
My Commission expires J Z~~
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(To be executed in duplicate and oriEinat fJed with Clerk Cacuit Court, and duplicale v~~th Tax Assessor)
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