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. D~:cla~~iti~n o1 Dornicite a~~d Citir.anst~ip ~
TO THE STATE AND COUNIY TAX ASSESSOR. 9c~~~
1Va~
51. LUCIE COUNTY, FIORiDA: _ '
This is my decla~a~ion of ~omicilo a~d Citizenship i~ the State of Flo~ida ~hat 1 am lili~g this day i~ accwda~ce a~d
in con{ormity wilh Chepte~ Z22, Scction 4?2.17, Florida Statutes.
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al ~esident of ' ----~~'~9'~
1 was fornnerly a leg
ity) a~~
and 1 resided at ,~~~a~^~
~~A'~ ~~'^~~''~L~ . However 1 have cha~ed my dornicJ~le
• (Streef and Number) •
to and am a~d have been a bo~a fide ~esident~ of the State of Florida :ince ~ d~y of
' , 19 , and 1 ~eside 'at , , • ~ ~ .
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FORT PIERCE, SAINT LUCIE COUNTY, FIORIDA
and this statement is to be taken as my detlaratio~ of citize~ship, attual legal ~esidente a~d domitile in the State of Notida.
qnse~t here a~y peninent facts,: such as sale of prope~ty or busi~eu, or ~elinquishme~t of employma+~t .
at forme~ doniicile, removal of family to ~ew domicile, _purcha:e of home. efc.) .
Applying, for Homestead ~
- Entering children in school ; ~ . _
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I FURTHER CERTIFY fhat 1 wili comply with all other requi~ements of a leyal resider~t of this Stale.
I FURTHER CERTIFY that I have no intention to tetu~n to my fomne~ domit~le. a~d 1 intend to remai~ in FORT
PIERCE, SAINT LUCIE COUNTY, FLORIDA, permanently. ~
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ROCER P,iTR~1: ~
r;, FN;:~,~,,_ CIERx C~RCUIT C0111lT ~a^^~~ ~
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~•.5,; ~ :s~u~'scriEi~ bcfo~e me this day of
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R~iG~~"~`o~taAS
CLERK CIRCU{T COURT . Notary Public
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gy ~ ~ p.C. My Commission expi~as .
~To be exoculcd in duplicals and originai filod wilh Clo~k Circulf Cou~1, and dupliuto with Tax Auosso~.) . ,
aQO~21~ P~~2350
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