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1 U TI1E STA1 E ANU CUU~li Y T/1X /1SSI.S.SC~R.
51. lUC1E ~OUN1Y, FlORIOA: - ~a
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This is my declaration of Domicile and Citizenship in the State of Flo~ida that 1 am liling this day in acto~dance and
in conformi~y with Chapter 222, Scdion 222.17, Flo~ida Statutes. ~
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1 was tormerly a legal resident of
(City) - (Stafe)
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arxi 1 resided at Z~ ST~'~K~~ ~ ~~~'V ~ Howeve~ 1 have changed my domiti~e ~
• ' (Street and Number) • ~
to and am a~d have been a bona fide resident of the State of Florida since day of ~
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~
' r , 19..z~, and I reside ~at ' S' ~ ~
- . (Street and Numbe~)
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fORT PIERCE. SAINT LUCIE COUNTY, FLORIOA - ~
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and this statement is to be taken as my declaration of citi=enship, adual legal residence and domicile in the State of Fbrida.
(Insen he~e any pertinent facts. such as sale of property or business, or ~elinquishment of employment
at forme~ domicile, removal of family to new ciomicile, purchase of home, etc.)
Applyinq~ for Homestead . - ;
- Entering children in school : - ~
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• . ~ - • ~EO ANfl liECOA~ .
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- CLERR GK~urT ~p~t y~1 ~ ~
_ ~ REC~RD 1tEt!f~~p`~r
~ ~ ~~F~'~y ~ l~~~~ - ~ ~ ~i 21 ~ ~73
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1 FURTHER CERTIFY that 1 will oomply with all other requirements of a legal resident of this State.
1 fURTHER CERTIFY that 1 have no intention to return to my former domitile, and I intend to remain in FORT
PIERCE, SAINT LUCfE COUNTY, FLORIDA, permanently. • ~~Oh N S- ~ ~~C o~o ? y~
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Swo~it tb
6~id •subscribed before me this day of
. .
ROGER POItRAS ~
CLERK CIRCUIT COURT Notary Public
~
ny D.C. My ~ommission expires
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(To bo oxecuted an duplicate and :~•~nal filed wilh Clerk Grcuit Cou~t, and duplicato with Tax Assoswr.)
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