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Declaration of Domicile and Citizensttip
240029
TO THE STATE AND COUNTY TAX ASSESSOR,
Sl. LUCIE COUNTY, FLORIDA:
This is my dccla~ation of Domicilc and Citizenship in the State of Florida that I am filing this day in accordance and
in conformity with Chapter 222, Section 222.17, Flo~ida Statutes. ~
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I was formerly a legal resident of _ ~ '
~ (City) (State)
and I resided at - However I have changed my domiCile
(Street and Number) ~
to and am and have been a bona fide resident of the State of Florida sinte day of =
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~ 19~? and 1 reside ~at ~ ' ~ ' ~
~ ~ ' (Sireet and Number)
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FORT PIERCE, SAINT LUCIE COUNTY, fLORIDA f
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and this statement is to be taken as my declarafion 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.)
Applying ~ for Homestead ? • °
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- Entering children in school : st' ~~R p~1ZA~5 ~ i
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t FURTHER CERTIFY that 1 will comply with all other requirements of a lega) resident of this State.
I FURTHER CERTIFY that I have no intention to return to my former domiCile, and I intend to remain in FORT
3
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. _
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(Address)
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Sworn to and subscribed before me this ' day of , 19 ~
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C~~tl~ 'Qf~tL" ~ ~T Notary Public
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E~y - - - D.C. My Commission expires
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';-.(Yb bo oxecuted in duplicate and oric~inal filed with Clerk Circuit Couvt, and duplicate with Tax Assessor.)
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