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Declaration ot Domicile and Citizenship ;
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TO THE STATE AND COUNTY TAX ASSESSOR, ;~35'712
Sl. IUCIE COUNIY, FIORIDA:
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This is my declaration of Domicile and Citi7enship in ihe State of Florida tliat 1 am filing this day in actardance and
+n conformity with Chapter ?22, ~ection 222.17, Florida Statutes.
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1 was formerly a legal resident of --~y ~L1~._~.~[~..------_--- - - -
(City) (Sfate)
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and I resided at i a_D C~~ However I have changed my domiCile
(St~eet and Number)
to and am and have been a bona fide resident of the State of Florida since _ day of
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~l~.__--- - . 19~~, and 1 reside at ~~i L n _ ~
(Street and Number)
FORT PIERCE, SAINT I.UCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in ihe State of Florida. +
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(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, eic.) •
FILEO ANQ RE_
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1 FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State. i
i FURTHER CERTIFY that I have no intentio~ to return to my former domitile, and 1 intend to remain in FORT
PfERCE, SAINT LUCIE COUNTY, FLORIDA, permaneNly_
, . (Name)
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• . , , _ ~ ~ ~ Y _~~k~~d' Gt ` 1
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Swom tp and subscribed before me this day of , 19~.~ ~
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ROGER POITRAS
CLERK CIRCUIT COURT Notary Public
By ~fd c D.C. My Commission expires
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(To be executed in duplicate and original filed with Clerk Circuit Court, and duplicato with Tax Assessor.)
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BOOK ~OJ PAGE 105~j ~
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