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• Dcclar~~t~~n ot DornicilQ a~~d CititQns~~ip
TO THE STATE AND COUNTY TAX ASSCSSOR, ~~5~~
Si . lUC1E COUNIY, FLORI~A:
This is my declaralion of Oomicile a~d Citizenship in~ the State of Flo~ide that I am filing this dAy in acco~dance and
in conformity with Chapter 222, Scction 222.17, Florida Statutes.
. ~ i- .
1 was formerly a legal resident of
(City) (State)
end ! resfded st~~ ~far./ . However 1 have changed my domici~e ~
~ (St~eet and Numbe~)
to and am end have been s bona fide resident of the State of Florids since ~,Qd~ day of
. .
19~~ and I reside ~at . ~ ,
~ . (Street and Number)
~ -
FORT PIERCE, SAINT WCtE COUNTY, ftORtDA ~
and this stetement is to be taken as my detlalation of citizenship, actual legal residence and domicile in the State of Florida.
(Insert hera any pertinent facts, such as sale of p~operty or business, or relinquisF~ment of employment
et former domicile, removal of family to new domicile, purchase of home, etc.) ~
Applyinq, for Homestead ~ ~ ,
- Entering childrean in school ; ~ ~
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, .
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- lII.EO AMO~pp
RD~p
• :T. ~UCtE COIJNTY ~LA. ~
OCER POITRAS
• CLERK CIRCUIT COUI1t '
. . RECORD YERtF1E0~
•
. ~ A~ 9 9 ss I~'x3 ~ .
251569
1 FURTHER CERTIFY that I will comply with ali other requ~rement: of a legat ~esident of fhis State.
I FURTHER CERTIFY that 1 have no intention to return to my former domicjle, and I intend to remain in FORT
PiERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. '
(Name)
/ , ~
A.
r -
;~~~~NU~~~lp~~., , . ~ . (Address)
~tl{7~C••~:.,~~~ , ~ . . -
q. .
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`~jny ~~~~~~ad before me this day of 1 , 19~
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' ~ _ ~,IRC~fI'~'COURT Notary Public
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aY ~.C. My ~ommission expirc+s
(To b~ oxowlod in duplicale and ~ ~nal filod with Cle~k Clrcuit Court, •nd dupliut~ with Tax Assesso~.j ~
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