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~eclaration ot Domicile and Citizenshi~
10 TliE S1A1E r+NU COUNTI' TAX ASSESSOit. 235958
51. lUC1E COUN f 1, FIURIDA:
This ~s n?y declaration of Dom~cile a~~d Citizenship in the State of Florida that I am filing Ihis day i~ accordance and
in conformity w~tii Chapter 222, Section 222.17, Florida Statutes. .
1 was formerly a legal resident af . ~ Al_~ . _ - ~ NL/
(City) - - - (State)
3~f ~~~~h~~ S-r
and I resided at _~_l___ - . However I have changed my domiCile
(St~eet and Number)
to and am and have been a bona fide resideni of the State of Florida since ~~G -_~_7- _ day of
- . - 19~ and I reside at _ ..~1~2b~__ v/ / //V C Y A v ~ -
(Street and Number)
FORT PIERCE, SAIN? LUCIE COUNTY, FLORIDA
and this statement is to be taken as my declaration of citizenship, actual legal residence and domicile in the State of Flo~ida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at forme~ domicile, reinovaf of family to new domicile, purchase of home, etc.) .
~.r~sA ~F_r t~'2ic~
~
S~lAvtilnA D~E ~RIC~ fIEDANDRE
s~ ~uc~~ cov~~.
CIfRKCC{RCUIT~ y~ [ ~
RECORQ VERt~tEO ~ ~
~ ~ ~ i~ ~ '7Z ~
;
~ 235958
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1 FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domi~ile, and I intend to remain in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
f
.C,t.,[.~L~
- (Name)
~ ' ~ ' D ' r/E
- . Address)
~ Sworrrfq~a~d`subscribed before me this ~ day of ~ , 19~'~'
~
ROGER POITRAS -
CLERK CIRCUIT COURT Notary Public
- Eiy ~C ~ u-~- D.C. My Commission expires
(To be executed in duplicate and original filed with Clerk Ci~cuit Court, and duplicate with Tax Assessor.)
~o~~ ~05 FA~E~.378
_ - _ _ x x~