HomeMy WebLinkAbout1235 Decl~rat~on ot Domicile and Citizenstiip
TO THE STATE AND COUNTY TAX AS.~ESSOR, ~t7JSS1
Sl. lUC1E COUNTY, FIORiDA~
This is my declaralion of Do:n~cile a~id Citizenship in the Sta~e of Florida that 1 am fiiing this day in accordance and
in conformity with Chapter 22?, Section 222.17, Florida Statutes.
I was formerly a legal resideM of a~-=--
`~i~~-- - Cit 1 (State)
( y
and 1 resided at ~~#J~ ~Q~i~ y~~~~~_~! . However I have changeci my domiCile
(Street and Number}
to and am and have been a bona fide resident of the State of Florida since ~ day of
~ /
19~~, and I reside at c~~~ y--- 'P°~ - - - -
- - -
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Florida.
(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, etc.)
i~~c. ~/~a.~ ~L~~ f 1.E0 ~M4 lIECORf~A.
- a~.lUC1E~
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1lECORD VEF~f EO C~R
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235851
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1 FURTHER CERTIFY that I will comply with al) other requirements of a legal resident of this State.
1 FURTHER CERTIFY that I have no intention to return to my former domic,ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
1 ~ .~~~I`dr,tr~/
~ - ~ (Name)
- . , ~e~o y RJ Q.,.~ ~ ~
~
.
~ . . . (Address)
~ .
~ Sworn to and subscribed before me this ~ z- day of , 19..~1~
~
ROGER POITRAS
CLERK CIRCUIT COURT Notary Public
By D.C_ My Commission expires _
(To be executed in duplicate and original filed wilh Clerk Circuit Court, snd duplicato with Tax Assessor.)
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